Axillary lymph node dissection for breast cancer utilizing Harmonic ...

Ostapoff et al. World Journal of Surgical Oncology 2011, 9:90http://www.wjso.com/content/9/1/90Page 2 of 5vascular and lymphatic conduits with limited collateraldamage.The Harmonic Focus ® is a handheld ultrasonic dissectiondevice which allows lymphatics to be sealed withoututilization of clips or ties. It has been available sinceOctober 2007 and is designed for open procedures. Ithas been used for dissection in surgery of the liver, gallbladder,thyroid and breast [13-18]. It has been used inother lymphatic dissections in an attempt to reducelymphatically related complications and has been shownto reduce operative times and reduce lymphatic spillagewith similar rates of lymph node harvest for both modifiedlateral neck dissections and central neck dissectionsin thyroid cancer[16,17]. The ultrasonic dissector hasalso been shown to reduce blood loss[12].We hypothesize that ALND performed with HarmonicFocus ® will decrease operative time and post-operativecomplications. Here we present our pilot study investigatingthe role of Harmonic Focus ® as method toreduce axillary complications.MethodsAll women at the University of Texas SouthwesternMedical Center undergoing ALND for confirmed breastcancer metastasis from January 1, 2005 to December 1,2009 were eligible. Nearly 250 ALND’s were performedduring this time period. In 2007, ultrasonic dissectionbecame the standard technique for ALND for 3 fellowshiptrained breast surgeons (RR, AM, DE) at this large,high volume, academic medical center. Twenty eightpatients underwent ALND with the Harmonic ® scalpel.Patient records were reviewed after IRB approval. Thesepatients were then matched for number and type of proceduresperformed at the time of ALND with thirteenhistorical case controls by procedure performed by thesame surgeons. All patients had pathologically confirmedaxillary metastasis prior to ALND by either sentinelnode biopsy or percutaneous axillary biopsy.Additionally, none of the patients in either group hadbreast reconstruction at the time of axillary dissection.Due to the surgeon preference for utilizing ultrasonicdissection once it became available, one to one matchedpair analysis was not possible, however, the thirteencontrols reviewed were performed by the same surgeonsthat performed the ultrasonic dissections to minimizesurgeon specific variables.SurgerySkin incisions were made with a scalpel. If concurrentbreast surgery occurred at the time of ALND, mastectomywas performed using either tumescent technique orbovie electrocautery. For axillary lymphadenectomy, alltissue inferior to the axillary vein, between the anteriorborder of the latissimus dorsi and medial to the borderof the pectoralis minor was removed, thus including alllevel 1 and 2 nodes. The axilla was closed with 3.0Vicryl interrupted suture and the skin was re-approximatedwith 4.0 Monocryl. At the time of surgery, 1closed suction 19 french Jackson-Pratt drain was placedfor patients with partial mastectomy and axillary dissectionand 2 closed suction drains were placed for modifiedradical mastectomy patients. Drains were thenremoved on an outpatient basis when output was lessthan 30 cc/day for 2 consecutive days. Operative timewas obtained by review of the anesthesia record andoperating room nurse record. Patients were dischargedroutinely on postoperative day one with drains in placeand self recorded the output after teaching.Incidence of ipsilateral lymphedema, seroma andwound complications was noted upon review of followupappointments in any department (Surgery/RadiationOncology, Medical Oncology or Emergency department).Categorical variables were analyzed using c 2 test,continuous variables were analyzed using ANOVA testingusing SPSS 12.0. All endpoint analyses were analyzedusing paired t-test. Multiple comparisons were notadjusted for.ResultsOver the 2 year period, 28 patients underwent axillarydissection using Harmonic scalpel ® .Medianfollow-uptime for both groups was 2.0 years. Patients in bothgroups had similar demographicsaswellaspathologyand exposure to chemotherapy (Table 1). Additionally,there was no statistically significant difference in T stagebetween the control and ultrasonic dissection group (p= 0.222). Patients were matched to controls undergoingsimilar procedures by the same surgeons (Table 2).There were no differences in operative time, postoperativeday 1 output or overall complications betweenthegroups.Therewasadifferenceindaystodrainremoval (15.9 vs 12.4 days p = 0.07), however, this wasnot statistically significant. There was no difference inrates of seromas, wound complications or lymphedemabetween the two groups (Table 3).DiscussionGiven the significant morbidity of ALND and the costsassociated with their management, multiple studies havetried to identify risks factors as well as methods toreduce complications. Risk factors for seroma formationinclude MRM rather than PM[9], use of electrocauteryfor ALND[19], older age, patient weight, BMI[20] anddrainage output at 48 hours (>50 cc/day)[21]. The roleof axillary drainage has been a particular area of focus.Drains have been shown to reduce seroma rates comparedto no drainage at all[21-23]. Lower overall drainvolume[24], days to drain removal[25,26] and drainage