Prevention and management of complications related to laparoscopic spleen-preserving hilar lymph node dissection for gastric cancer / 中华胃肠外科杂志

Hilar splenic lymph node metastasis is one of the risk factors for poor prognosis in patients with proximal gastric cancer. Laparoscopic spleen-preserving splenic hilar lymph node dissection (LSPSHLD) can effectively improve the survival benefits of patients at high risk of splenic hilar lymph node metastasis. However, LSPSHLD is still a challenging surgical difficulty in radical resection of proximal gastric cancer. Moreover, improper operation can easily lead to splenic vascular injury, spleen injury and pancreatic injury and other related complications, due to the deep anatomical location of the splenic hilar region and the intricate blood vessels.Therefore, in the prevention and treatment of LSPSHLD-related complications, we should first focus on prevention, clarify the indication of surgery, and select the benefit group of LSPSHLD individually, so as to avoid the risk caused by over-dissection. Meanwhile, during the perioperative period of LSPSHLD, it is necessary to improve the cognition of related risk factors, conduct standardized and accurate operations in good surgical field exposure and correct anatomical level to avoid surrounding tissues and organs injury, and master the surgical skills and effective measures to deal with related complications, so as to improve the surgical safety of LSPSHLD.

Current status and future prospects of robotic surgical system in radical gastrectomy for gastric cancer / 中华胃肠外科杂志

Robotic gastrectomy (RG) has always been a hot topic in the field of minimally invasive surgery for gastric cancer. More and more studies have confirmed that short- and long-term outcomes of RG are similar to those of laparoscopic gastrectomy. Robotic surgical systems have more advantages in specific regional lymph node dissection. More delicate operation can reduce intraoperative blood loss and the incidence of postoperative complications. Robotic surgical systems are also more ergonomically designed. However, there are also some problems such as high surgical cost, lack of tactile feedback and prolonged total operation time. In the future, robotic surgical system may be further developed in the direction of miniaturization, intelligence and modularity. At the same time, the robotic surgical system deeply integrated with artificial intelligence technology may realize the automation of some operation steps to some extent.

Effects of gastrectomy on quality of life of patients with gastric cancer and its evaluation methods / 中华胃肠外科杂志

Surgery is the main curative treatment for gastric cancer. As surgical techniques continue to improve, the scope of radical resection and lymph node dissection has formed consensus and guidelines, so people's attention has gradually shifted to the quality of life (QOL) of patients after surgery. Postgastrectomy syndrome is a series of symptoms and signs caused by complications after gastrectomy, which can affect the quality of life of patients with gastric cancer after surgery. Gastrectomy and anastomosis are closely related to postgastrectomy syndrome. The selection of appropriate surgical methods is very important to the quality of life of patients after surgery. This article reviews the effects of gastrectomy procedures on postoperative quality of life of patients with gastric cancer and its evaluation methods.

Precauções para linfedema em mulheres acometidas por câncer de mama pós esvaziamento axilar: revisão de escopo / Precautions against lymphedema in women with breast cancer after axillary dissection: scoping review / Precauciones para el linfedema em mujeres com câncer de mama después del vaciamento axilar: revision de alcance

Objetivo: identificar e mapear estratégias preconizadas para prevenção de linfedema em pacientes submetidas a esvaziamento axilar em tratamento do câncer de mama. Método: revisão de escopo realizada em agosto de 2019 considerando oito bases de dados e oito bases da literatura cinzenta. A amostra final foi composta por 13 artigos, selecionados de acordo com critérios de elegibilidade. Resultados: os estudos foram predominantemente randomizados, com nível de evidência 1a, e realizados na América do Norte. Medidas preventivas tradicionalmente utilizadas, como limitar exercícios com carga ou evitar punção venosa e aferição de pressão arterial, não se demonstraram efetivas em nenhum dos estudos encontrados. Foi evidenciado como medida preventiva o controle dos fatores de risco modificáveis associados ao linfedema: IMC elevado (> 25 kg/m2 ) e quimioterapia administrada no braço ipsilateral. Conclusões: não foram apresentadas evidências significativas para medidas cotidianamente preconizadas na prevenção do linfedema, e fatores de risco modificáveis se destacaram entre os riscos para seu desenvolvimento.

Objective: to identify and map strategies recommended for prevention of lymphedema in patients after axillary dissection during breast cancer treatment. Method: this scoping review was conducted in August 2019 across eight databases and eight gray literature data sources. The final sample comprised 13 journal articles that met eligibility criteria. Results: the studies, most of which were randomized, conducted in North America, and offered Level 1a evidence. None of the studies reviewed found traditionally employed preventive measures, such as limiting weight training or avoiding venipuncture and blood pressure measurements, to be effective. Evidence indicated that controlling modifiable lymphedema-related risk factors ­ namely high BMI (> 25 kg/m²) and chemotherapy administration in the ipsilateral arm ­ was a preventive measure. Conclusion: no significant evidence was reported for traditionally recommended preventive measures against lymphedema, and modifiable factors figured prominently among risk factors for lymphedema.

Objetivo: identificar y mapear las estrategias recomendadas para la prevención del linfedema en pacientes después de una disección axilar durante el tratamiento del cáncer de mama. Método: esta revisión de alcance se realizó en agosto de 2019 en ocho bases de datos y ocho fuentes de datos de literatura gris. La muestra final comprendió 13 artículos de revistas que cumplieron con los criterios de elegibilidad. Resultados: los estudios, la mayoría de los cuales fueron aleatorios, se realizaron en Norteamérica y ofrecieron evidencia de Nivel 1a. Ninguno de los estudios revisados encontró que las medidas preventivas empleadas tradicionalmente, como limitar el entrenamiento con pesas o evitar la punción venosa y las mediciones de la presión arterial, sean efectivas. La evidencia indicó que el control de los factores de riesgo relacionados con el linfedema modificables, a saber, un IMC alto (> 25 kg / m²) y la administración de quimioterapia en el brazo ipsilateral, era una medida preventiva. Conclusión: no se informó evidencia significativa de las medidas preventivas recomendadas tradicionalmente contra el linfedema, y los factores modificables figuraron de manera prominente entre los factores de riesgo para el linfedema.

Linfadenectomía transcervical diagnóstico-terapéutica en el carcinoma pulmonar de células no pequeñas / Diagnostic-therapeutic transcervical lymphadenectomy in non-small cell lung carcinoma

El cáncer de pulmón es el tumor más frecuente del árbol respiratorio y el que origina mayor número de muertes. Uno de los objetivos más importantes en su manejo es la estadificación, de la cual, el análisis de los ganglios linfáticos del mediastino es de suma importancia para definir los pacientes que pueden recibir cirugía. Para el estudio ganglionar invasivo, la linfadenectomía transcervical ocupa un lugar importante cuando existe evidencia de afectación ganglionar de la zona superior como método diagnóstico y terapéutico inicial en pacientes que después de quimioterapia de inducción y re-estadificación reúnen las condiciones para resección. Se presenta este trabajo con el objetivo de mostrar a la comunidad quirúrgica, la linfadenectomía transcervical utilizada para el diagnóstico y tratamiento del carcinoma pulmonar de células no pequeñas en el Hospital Provincial Universitario Manuel Ascunce Domenech de Camagüey por el grupo de cirugía torácica(AU)

Lung cancer is the most common tumor of the respiratory tract and the one casing more deaths. One of the most important objectives in its treatment is stage characterization, for which analyzing mediastinal lymph nodes is paramount to define patients who can receive surgery. For the nodal invasive study, transcervical lymphadenectomy occupies an important place, when there is evidence of lymph node involvement in the upper area as an initial diagnostic and therapeutic method in patients who, after inducted chemotherapy and stage characterization, are candidates for resection. This work is presented with the aim to present to the surgical community the transcervical lymphadenectomy used by the group of thoracic surgery for diagnosis and treatment of non-small cell lung carcinoma at the Manuel Ascunce Domenech University Provincial Hospital of Camagüey(AU)

Radical cystectomy with pelvic lymphadenectomy: pathologic, operative and morbidity outcomes in a Brazilian cohort

ABSTRACT Introduction and Objective Radical cystectomy (RC) with pelvic lymph node dissection is the standard treatment for muscle invasive bladder cancer and the oncologic outcomes following it are directly related to disease pathology and surgical technique. Therefore, we sought to analyze these features in a cohort from a Brazilian tertiary oncologic center and try to identify those who could negatively impact on the disease control. Patients and Methods We identified 128 patients submitted to radical cystectomy, for bladder cancer treatment, from January 2009 to July 2012 in one oncology tertiary referral public center (Mario Penna Institute, Belo Horizonte, Brazil). We retrospectively analyzed the findings obtained from their pathologic report and assessed the complications within 30 days of surgery. Results We showed similar pathologic and surgical findings compared to other large series from the literature, however our patients presented with a slightly higher rate of pT4 disease. Positive surgical margins were found in 2/128 patients (1.5%). The medium number of lymph nodes dissected were 15. Major complications (Clavien 3 to 5) within 30 days of cystectomy occurred in 33/128 (25.7%) patients. Conclusions In the management of invasive bladder cancer, efforts should focus on proper disease diagnosis and staging, and, thereafter, correct treatment based on pathologic findings. Furthermore, extended LND should be performed in all patients with RC indication. A critical analysis of our complications in a future study will help us to identify and modify some of the factors associated with surgical morbidity.

Single-port laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy as part of staging operation for early ovarian cancer and high grade endometrial cancer / 부인종양

OBJECTIVE: The aim of this paper was to demonstrate the techiniqes of single-port laparoscopic transperitoneal infrarenal paraaortic lymphadenectomy as part of surgical staging procedure in case of early ovarian cancer and high grade endometrial cancer. METHODS: After left upper traction of rectosigmoid, a peritoneal incision was made caudad to inferior mesenteric artery. Rectosigmoid was mobilized, and then the avascular space of the lateral rectal portion was found by using upward traction of rectosigmoid mesentery. Inframesenteric nodes were removed without injury to the ureter and the left common iliac nodes were easily removed due to the upward traction of the rectosigmoid. The superior hypogastric plexus was found overlying the aorta and sacral promontory, and presacral nodes were removed at subaortic area. Peritoneal traction suture to right abdomen was needed for right para-aortic lymphadenectomy. After right lower para-aortic node dissection, operator was situated between the patient's legs. After upper traction of the small bowel, left upper para-aortic nodes were removed. To prevent chylous ascites, we used hemolock or Ligasure application (ValleyLab Inc.) to upper part of infrarenal and aortocaval nodes. RESULTS: Single-port laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy was performed without serious perioperative complications. CONCLUSION: Even though the technique of single-port surgery is still a difficult operation, the quality of single-port laparoscopic transperitoneal infrarenal para-aortic node dissection is excellent, especially mean number of para-aortic nodes. In cases of staging procedures for ovary and endometrial cancer, single-port transperitoneal para-aortic lymphadenectomy is acceptable as an oncologic procedure.

The risk of lymphedema after postoperative radiation therapy in endometrial cancer / 부인종양

OBJECTIVE: Lower extremity lymphedema adversely affects quality of life by causing discomfort, impaired mobility and increased risk of infection. The goal of this study is to investigate factors that influence the likelihood of lymphedema in patients with endometrial cancer who undergo adjuvant radiation with or without chemotherapy. METHODS: A retrospective chart review identified all stage I-III endometrial cancer patients who had a hysterectomy with or without complete staging lymphadenectomy and adjuvant radiation therapy between January 2006 and February 2013. Patients with new-onset lymphedema after treatment were identified. Logistic regression was used to find factors that influenced lymphedema risk. RESULTS: Of 212 patients who met inclusion criteria, 15 patients (7.1%) developed new-onset lymphedema. Lymphedema was associated with lymph-node dissection (odds ratio [OR], 5.6; 95% CI, 1.01 to 105.5; p=0.048) and with the presence of pathologically positive lymph nodes (OR, 4.1; 95% CI, 1.4 to 12.3; p=0.01). Multivariate logistic regression confirmed the association with lymph-node positivity (OR, 3.2; 95% CI, 1.0007 to 10.7; p=0.0499) when controlled for lymph-node dissection. Median time to lymphedema onset was 8 months (range, 1 to 58 months) with resolution or improvement in eight patients (53.3%) after a median of 10 months. CONCLUSION: Lymph-node positivity was associated with an increased risk of lymphedema in endometrial cancer patients who received adjuvant radiation. Future studies are needed to explore whether node-positive patients may benefit from early lymphedema-controlling interventions.

When Eastern Surgeons Meet Western Patients: A Pilot Study of Gastrectomy with Lymphadenectomy in Caucasian Patients at a Single Korean Institute

East Asian surgeons generally report lower morbidity and mortality rates for gastrectomy with D2 lymphadenectomy than do surgeons in Western countries; however, the disparity remains unexplained. The aim of this article was to determine the feasibility and safety regarding cases in which East Asian surgeons perform such procedures in Caucasian patients (CPs). Twelve CPs underwent gastrectomy with lymphadenectomy for gastric cancer at Yonsei University Severance Hospital, Seoul, Korea between June 2011 and April 2014. Procedures performed included total gastrectomy (7 of 12, 58%), distal gastrectomy (4 of 12, 33%), and completion total gastrectomy (1 of 12, 8%). Nine patients (75%) underwent D2 lymphadenectomy, and D1+ lymphadenectomy was performed in three others (25%). In four patients (33%), combined resections were carried out. The median values of surgical parameters were as follows: operative time, 266.5 min (range, 120-586 min); estimated blood loss, 90 mL (range, 37-350 mL); retrieved lymph node count, 37.5 (range, 22-63); and postoperative hospital stay, 13.7 days (range, 5-63 days). No mortality was encountered, although two patients (17%) experienced complications (both Clavien-Dindo classification grade IIIa anastomotic leakages), which were successfully managed by conservative treatment. In the hands of East Asian surgeons, mortality and short-term morbidity appears to be acceptably low in CPs subjected to gastrectomy with lymphadenectomy for gastric cancer.

Risk factor analysis for massive lymphatic ascites after laparoscopic retroperitonal lymphadenectomy in gynecologic cancers and treatment using intranodal lymphangiography with glue embolization / 부인종양

OBJECTIVE: To evaluate risk factors for massive lymphatic ascites after laparoscopic retroperitoneal lymphadenectomy in gynecologic cancer and the feasibility of treatments using intranodal lymphangiography (INLAG) with glue embolization. METHODS: A retrospective analysis of 234 patients with gynecologic cancer who received laparoscopic retroperitonal lymphadenectomy between April 2006 and November 2015 was done. In June 2014, INLAG with glue embolization was initiated to manage massive lymphatic ascites. All possible clinicopathologic factors related to massive lymphatic ascites were determined in the pre-INLAG group (n=163). Clinical courses between pre-INLAG group and post-INLAG group (n=71) were compared. RESULTS: In the pre-INLAG group (n=163), four patients (2.5%) developed massive lymphatic ascites postoperatively. Postoperative lymphatic ascites was associated with liver cirrhosis (three cirrhotic patients, p<0.001). In the post-INLAG group, one patient with massive lymphatic ascites had a congestive heart failure and first received INLAG with glue embolization. She had pelvic drain removed within 7 days after INLAG. The mean duration of pelvic drain and hospital stay decreased after the introduction of INLAG (13.2 days vs. 10.9 days, p=0.001; 15.2 days vs. 12.6 days, p=0.001). There was no evidence of recurrence after this procedure. CONCLUSION: Underlying medical conditions related to the reduced effective circulating volume, such as liver cirrhosis and heart failure, may be associated with massive lymphatic ascites after retroperitoneal lymphadenectomy. INLAG with glue embolization can be an alternative treatment options to treat leaking lymphatic channels in patients with massive lymphatic leakage.

Risk factor analysis for massive lymphatic ascites after laparoscopic retroperitonal lymphadenectomy in gynecologic cancers and treatment using intranodal lymphangiography with glue embolization / 부인종양

OBJECTIVE: To evaluate risk factors for massive lymphatic ascites after laparoscopic retroperitoneal lymphadenectomy in gynecologic cancer and the feasibility of treatments using intranodal lymphangiography (INLAG) with glue embolization. METHODS: A retrospective analysis of 234 patients with gynecologic cancer who received laparoscopic retroperitonal lymphadenectomy between April 2006 and November 2015 was done. In June 2014, INLAG with glue embolization was initiated to manage massive lymphatic ascites. All possible clinicopathologic factors related to massive lymphatic ascites were determined in the pre-INLAG group (n=163). Clinical courses between pre-INLAG group and post-INLAG group (n=71) were compared. RESULTS: In the pre-INLAG group (n=163), four patients (2.5%) developed massive lymphatic ascites postoperatively. Postoperative lymphatic ascites was associated with liver cirrhosis (three cirrhotic patients, p<0.001). In the post-INLAG group, one patient with massive lymphatic ascites had a congestive heart failure and first received INLAG with glue embolization. She had pelvic drain removed within 7 days after INLAG. The mean duration of pelvic drain and hospital stay decreased after the introduction of INLAG (13.2 days vs. 10.9 days, p=0.001; 15.2 days vs. 12.6 days, p=0.001). There was no evidence of recurrence after this procedure. CONCLUSION: Underlying medical conditions related to the reduced effective circulating volume, such as liver cirrhosis and heart failure, may be associated with massive lymphatic ascites after retroperitoneal lymphadenectomy. INLAG with glue embolization can be an alternative treatment options to treat leaking lymphatic channels in patients with massive lymphatic leakage.

Robot-Assisted Extended Pelvic Lymph Nodes Dissection for Prostate Cancer: Personal Surgical Technique and Outcomes

Objective: Extended pelvic lymph nodes dissection (EPLND) allows the removal of a higher number of lymph nodes than limited PLND. The aims of this study were to describe our robot-assisted EPLND (RAEPLND) technique with related complications, and to report the number of lymph nodes removed and the rate of lymph nodal metastasis. Materials and Methods: 153 patients underwent RAEPLND prior to robot-assisted radical prostatectomy (RARP). Indications were defined according to Briganti nomogram, to predict risk of lymph-nodal metastasis. Lymphatic packages covering the distal tract of the common iliac artery, the medial portion of the external iliac artery, the external iliac vein and the internal iliac vessels, together with the obturator and the presacral lymphatic packages were removed on both sides. Results: Median preoperative PSA was 7.5 ng/mL (IQR 5.5–11.5). Median operative time was 150 min (135–170). Median RAEPLND alone operative time was 38 min (32.75–41.25); for right and left side, 18 (15–29) and 20 min (15.75–30) (p=0.567). Median number of lymph nodes retrieved per patient was 25 (19.25–30); 13 (11–16) and 11 (8–15) for right and left side. In 19 patients (12.41%) metastasis was found at the level of pelvic lymph nodes. Median number of positive lymph nodes was 1 (1–4.6) per patient. Complications occurred in 11 patients (7.3%). Conclusions: the number of lymph nodes removed was comparable to published data about open series, allowing the increase of detection rate of lymph nodal metastasis for minimally invasive approach without compromising complications' rate if performing the procedure following reported technique.

Feasibility, complications and oncologic results of a limited inguinal lymph node dissection in the management of penile cancer

In patients with penile cancer (PeCa) and increased risk of inguinal lymphatic dissemination, inguinal lymphadenectomy offers a direct histological staging as the most reliable tool for assessment of the nodal metastasic status and a definitive oncologic treatment simultaneously. However, peri- and/or postoperative mutilating sequalae often occurn. We report on clinical outcome and complications of a limited inguinal lymph node (LN) dissection.

Tratamento fisioterapêutico na Síndrome da Rede Axilar: proposição de um plano de cuidados / Physical therapy treatment in Axillary Network Syndrome: proposing a care plan

Complicações no membro superior encontram-se entre as principais repercussões após a cirurgia do câncer de mama e remoção dos linfonodos axilares, sendo a Síndrome da Rede Axilar (SRA) uma condição comumente observada no pós-operatorio imediato, e que consiste no surgimento de um cordoamento tenso e doloroso, oriundo da região axilar, que gera restrição de movimento no braço homolateral à cirurgia, e é decorrente do processo de cicatrização, que por sua vez é fundamental para o sucesso da cirurgia. A SRA pode causar incapacidade funcional no membro superior, especialmente por estar associada à restrição da amplitude de movimento do ombro e à dor, sendo o comprometimento da função do ombro mais um fator limitante nas atividades da vida diária (AVDs), de higiene pessoal, e na sua autonomia, o que repercute também no estado emocional da mulher. Apesar de ser descrita como uma síndrome autolimitada, com remissão espontânea em até 3 meses de seu surgimento, estudos mostram que, em alguns casos, ela pode estender-se além desse prazo, ou mesmo sofrer recidiva e piorar a incapacidade. Um agravante é o fato de ser uma questão subvalorizada na prática clínica, e por não haver orientação formal às pacientes sobre o risco de surgimento da síndrome, o tratamento costuma ser realizado tardiamente, o que pode prolongar o comprometimento funcional. A intervenção fisioterapêutica tem sido utilizada no pré e pós-operatório das cirurgias de mama para evitar as limitações físico-funcionais decorrentes da cirurgia, porém, o seu uso na SRA não está bem consolidada na literatura, bem como as estratégias educacionais sobre a síndrome ainda não fazem parte da rotina das orientações fisioterapêuticas pós-operatórias, de forma que as pacientes desconhecem os sinais, sintomas e características da SRA. Desta forma, os objetivos do presente trabalho foram: caracterizar o perfil sóciodemográfico e de saúde das mulheres submetidas ao tratamento cirúrgico para câncer de mama em um Hospital Universitário; relatar o efeito da intervenção fisioterapêutica precoce póscirúrgica para câncer de mama devido à SRA a partir do estudo de caso; elaborar um Plano de cuidados fisioterapêuticos de rotina no referido hospital e elaborar material educacional em forma de cartilha informativa para as pacientes em pós-cirúrgico de câncer de mama

Among the main repercussions after surgery for breast cancer and removal of axillary lymph nodes are complications in the arm. The healing process is critical to the success of the surgery, but may result in Axillary Web Syndrome (AWS) a commonly observed condition in the immediate post-operative, and that is the emergence of a tense and painful stranding, arising from the axillary region, generating restriction of movement in the ipsilateral arm surgery. AWS can cause functional impairment in the upper limb, especially to be associated with the restriction of shoulder range of motion and pain, and impairment of shoulder function more a limiting factor in activities of daily living (ADLs), personal hygiene, and their autonomy, which also affects the emotional state of women. Despite being described as a self-limited syndrome with spontaneous remission within 3 months of its inception, studies show that in some cases it may extend beyond that period, or even suffer relapse and worsen disability. An aggravating factor is the fact that it is a matter undervalued in clinical practice, and there is no formal guidance to patients about the risk of developing the syndrome, treatment is usually performed later, which can prolong the functional impairment. The physical therapy intervention has been used before and after surgery of breast surgery to avoid the physical and functional limitations resulting from surgery, however, its use in AWS is not well established in the literature, as well as educational strategies on the syndrome yet not part of the routine of postoperative physical therapy guidelines, so that the patients are unaware of the signs, symptoms and characteristics of AWS. Thus, the objectives of this study were to characterize the socio-demographic and health profiles of women undergoing surgery for breast cancer in a university hospital; report the effect of postoperative early physical therapy intervention for breast cancer due to AWS; develop a routine physical therapy care plan in that hospital and prepare an information booklet to patients in post-surgical breast cancer

Prevention of lymphocele development in gynecologic cancers by the electrothermal bipolar vessel sealing device / 부인종양

OBJECTIVE: A number of new techniques have been developed to prevent lymphocele formation after pelvic lymphadenectomy in gynecologic cancers. We assessed whether the electrothermal bipolar vessel sealing device (EBVSD) could decrease the incidence of postoperative lymphocele secondary to pelvic lymphadenectomy. METHODS: A total of 321 patients with gynecologic cancer underwent pelvic lymphadenectomy from 2005 to 2011. Pelvic lymphadenectomy without EBVSD was performed in 134 patients, and pelvic lymphadenectomy with EBVSD was performed in 187 patients. We retrospectively compared the incidence of lymphocele and symptoms between both groups. RESULTS: Four to 8 weeks after operation, 108 cases of lymphocele (34%) were detected by computed tomography scan examination. The incidence of lymphocele after pelvic lymphadenectomy was 56% (75/134) in the tie ligation group, and 18% (33/187) in the EBVSD group. We found a statistically significant difference in the incidence of lymphocele between both groups (p<0.01). To detect the independent risk factor for lymphocele development, we performed multivariate analysis with logistic regression for three variables (device, number of dissected lymph nodes, and operation time). Among these variables, we found a significant difference (p<0.001) for only one device. CONCLUSION: Use of the EBVSD during gynecological cancer operation is useful for preventing the development of lymphocele secondary to pelvic lymphadenectomy.

Factores asociados a mayor débito de drenaje tras linfadenectomía axilar por cáncer de mama / Factors associated with greater debit drainage after axillary lymphadenectomy for breast cancer

Introduction: axillary lymph node dissection (ALND) is still a usual procedure in the treatment of breast cancer. A drain is normally placed in the surgical bed and maintained several days until obtaining a daily discharge of 30-50 ml, in order to reduce the appearance of seroma. The aim of this study was to analyze possible factors associated with an increased drainage volume. Patients and Methods: a retrospective study of all the patients undergoing ALND for breasts cancer at our institution between 2011 and 2012 was performed. Results: 40 females were included. There were no complications or mortality. Median hospital stay was 2 days. Median day of drainage removal was the 5th postoperative day. Mean total drainage volume was 298.9 +/- 240.1 ml. High blood pressure associated with an increased drainage volume (550 ml vs 217.5 ml; p = 0.001) and a later removal (8th vs 4th day; p = 0.002). Similar happened with age > 65 years (420.8 ml vs 24.6 ml; p = 0.003) and (7th vs 5th day; p = 0.009). The number of metastatic lymph nodes showed a direct correlation with total drainage volume (Pearson 0.503; p = 0.017) and removal day (Spearman 0.563; p = 0.006), similar to the primary tumour size: total drainage volume (Pearson 0.447; p = 0.042) and removal day (Spearman 0.556; p = 0.009). Conclusion: age over 65 years, high blood pressure, number of metastatic lymph nodes and primary tumour size associated with a higher drainage volume and time to remove the drain.

Introducción: la linfadenectomía axilar (LA) sigue siendo un procedimiento frecuente en el tratamiento del cáncer de mama. Habitualmente se coloca un drenaje en el hueco axilar, que se mantiene varios días, hasta que tiene un débito diario de 30-50 ml, con el fin de reducir la aparición de seroma. El objetivo del presente estudio es analizar posibles factores asociados a un mayor volumen de drenaje. Pacientes y Métodos: realizamos un estudio retrospectivo de todas las pacientes intervenidas de LA por cáncer de mama en nuestro centro durante los años 2011 y 2012. Resultados: incluimos 40 mujeres en el estudio. No hubo complicaciones ni mortalidad. La mediana de estancia hospitalaria fue de 2 días. El día mediano de retirada de drenaje fue el 5° postoperatorio. El volumen medio total del drenaje fue 298,9 +/- 240,1 ml. La hipertensión arterial se asocia a un mayor volumen de drenaje (550 ml vs 217,5 ml; p = 0,001) y a una retirada más tardía del mismo (8° día vs 4° día; p = 0,002). Al igual ocurre con la edad > 65 años (420,8 ml vs 24,6 ml; p = 0,003) y (7° vs 5° día; p = 0,009). El número de ganglios metastásicos también se correlaciona con el volumen total de drenaje (coeficiente de correlación de Pearson 0,503; p = 0,017) y con el día de retirada (Spearman 0,563; p = 0,006), lo mismo que el tamaño del tumor primario: volumen total de drenaje (Pearson 0,447; p = 0,042) y día de retirada (Spearman 0,556; p = 0,009). Conclusión: la edad mayor de 65 años, la hipertensión arterial, el número de ganglios metastásicos y el tamaño del tumor primario se asocian con mayor volumen por el drenaje axilar y días necesarios hasta la retirada.

Alterações venosas e linfáticas em mulheres com linfedema após linfadenectomia axilar no tratamento do câncer de mama / Venous and lymphatic alterations in women with lymphedema after axillary lymphadenectomy in breast cancer treatment

OBJETIVO: Avaliar as alterações do sistema venoso axilo-subclávio e do sistema linfático em mulheres com linfedema após linfadenectomia axilar para o tratamento do câncer de mama. MÉTODOS: Trata-se de um estudo de série de casos, envolvendo 11 mulheres com linfedema unilateral de membro superior após linfadenectomia axilar para o tratamento do câncer de mama. O estudo foi realizado em hospital universitário do Brasil Central no período compreendido entre os meses de março de 2010 e março de 2011. Avaliou-se a presença de alterações venosas nas veias subclávia e axilar, por meio do exame de ultrassonografia com dopplervelocimetria, e de alterações linfáticas, pela linfocintilografia, em ambos os membros superiores. O teste Exato de Fisher foi utilizado na comparação entre os membros. RESULTADOS: No membro superior com linfedema, detectou-se diferença significativa na veia subclávia, em relação ao membro contralateral, quanto ao volume do fluxo (p<0,001), sendo que 54,6% das mulheres apresentaram fluxo aumentado. Já, na veia axilar, 45,4% apresentaram fluxo aumentado e 45,4% reduzido, com diferença significante (p<0,01) na comparação entre os membros. Também foram observadas alterações linfáticas significativas (p<0,05), em relação ao membro contralateral, representadas pelo trajeto do vaso (não visibilizado), número de vasos linfáticos (nenhum), linfonodos axilares (ausentes) e refluxo dérmico (presente). No membro superior contralateral sem linfedema, não foram encontradas alterações venosas ou linfáticas. CONCLUSÃO: As mulheres submetidas à linfadenectomia axilar para o tratamento do câncer de mama apresentam tanto alterações venosas quanto linfáticas no membro superior com linfedema.

PURPOSE: To evaluate changes in the venous axillary-subclavian and lymphatic systems of women with lymphedema after axillary lymphadenectomy for breast cancer treatment. METHODS: This was a case series involving 11 women with unilateral upper limb lymphedema after axillary lymphedenectomy for the treatment of breast cancer. The study was carried out in the Mastology Program of the Clinical Hospital of the Federal University of Goiás, Goiânia, GO, during the period between March 2010 and March 2011. Doppler velocimetry ultrasonography was used to detect the presence of venous changes in the subclavian and axillary veins. Lymphatic changes were evaluated by lymphoscintigraphy in both upper limbs. Fisher's exact test was used for the comparison between limbs. RESULTS: Subclavian vein flow volume in the upper limb with lymphedema was significantly different from that in the contralateral limb (p<0.001), 54.6% of the women had increased flow. In the axillary vein, 45.4% had increased flow and 45.4% had decreased flow, with a statistically significant difference (p<0.01) between limbs. Compared to the contralateral limb, significant lymphatic changes (p<0.05) were also found in the vessel route (not visualized), number of lymphatic vessels (none), axillary lymph nodes (absent) and dermal reflux (present). In the contralateral upper limb without lymphedema, no venous or lymphatic alterations were encountered. CONCLUSION: The women subjected to axillary lymphadenectomy for the treatment of breast cancer presented both venous and lymphatic changes in the upper limb with lymphedema.

Sensibilidade tátil no membro superior de mulheres submetidas à linfonodectomia axilar por câncer de mama / Tactile sensibility in arm of women subjected to the axillary lymph node dissection for breast cancer

OBJETIVO: identificar a alteração de sensibilidade no trajeto do nervo intercostobraquial utilizando um estesiômetro e observar a repetição das medições efetuadas com esse aparelho. MÉTODOS: foi aplicado o estesiômetro de Semmes-Weinstein para a avaliação da sensibilidade no trajeto do nervo intercostobraquial. Participaram desse estudo 94 mulheres divididas em dois grupos: Grupo CA, composto por 47 mulheres submetidas à linfonodenectomia axilar por câncer de mama, e grupo comparativo, composto por 47 mulheres sem câncer de mama e que não foram submetidas a qualquer tipo de cirurgia nas axilas. Em cada participante, foram realizadas anamnese e aplicação do estesiômetro duas vezes consecutivas. As respostas ao teste com estesiômetro do Grupo Controle foram utilizadas como valores de referência de normalidade. RESULTADOS: a prevalência de alteração de sensibilidade, no Grupo CA, foi de 85,1 por cento, com base nas repostas do Grupo Controle. Foi confirmada a repetição na aplicação do estesiômetro no Grupo CA por meio do teste de Kappa (p=0,8). CONCLUSÕES: na amostra desse estudo, as alterações de sensibilidade tiveram alta prevalência; as avaliações efetuadas com o uso do estesiômetro apresentaram repetição e, por isto, considerou-se o equipamento confiável para avaliação da sensibilidade no trajeto do nervo intercostobraquial.

PURPOSE: to identify sensitivity alteration in the intercostal brachial nerve pathway using an extensiometer, and to observe the measurement reproducibility of the apparatus. METHODS: the Semmes-Weinstein extensiometer was used to evaluate the sensitivity along the intercostal brachial nerve pathway. Ninety-four women have participated in the study, divided into two groups: a CA Group composed of 47 women submitted to breast cancer axillary lymphadenectomy, and a comparative group composed of 47 women without breast cancer, who had not been submitted to any kind of axillary surgery. Each participant underwent anamnesis and two consecutive applications of the extensiometer. The Control Group responses to the extensiometer test were used as normality reference values. RESULTS: based on Control Group responses, the prevalence of sensitivity changes was 85.1 percent in the CA Group. Reproducibility of the extensiometer application was confirmed in the CA Group through the Kappa's test (p=0.8). CONCLUSIONS: in this studied sample, sensitivity alterations had high prevalence; evaluations made with the extensiometer were reproducible, and thus we consider the equipment reliable to evaluate sensitivity along the intercostal brachial nerve pathway.