Komplikationen in der Mammachirurgie – Serome

Zusammenfassung

Mit einer Inzidenz von bis zu 81 % stehen Serome an der Spitze postoperativer Nebenwirkungen. Jedoch werden nur ca. 15 % durch Folgekomplikationen wie Infektionen und sekundäre Wundheilungsstörungen zum klinisch relevanten Problem. Die Entstehung von Seromen ist multifaktoriell, basiert auf der Reaktion auf mechanische und thermische Gewebezerstörung, verstärkt durch exsudativ-(pro)inflammatorische Prozesse, und ist eng mit dem entstandenen „Totraum“ im Wundgebiet verknüpft. Der Umfang des operativen Eingriffs im Bereich der Brust und Axilla ist nur bedingt für die Serombildung verantwortlich. Die Untersuchungen einer Vielzahl von hypothetischen Risikofaktoren zeigten keine konklusiven Resultate. Eine Vielzahl von Serom-minimierenden Verfahren wurde untersucht. Fibrin-basierte Gewebeklebstoffe führten nicht zu relevanten Verbesserungen. Die Art und Weise der Gewebedissektion wurde in einigen Untersuchungen als beeinflussender Faktor identifiziert. Einzig die Verminderung des Totraums der Wundhöhle durch innere Nähte führt bisher zu signifikanter Seromminderung mit den Nachteilen der Operationszeitverlängerung und der Ausbildung innerer Narben. Die Drainierung von Wunden ist Behandlungsstandard, der jedoch nicht unumstritten ist. Erste positive Erfahrungen wurden mit einem Urethan-basierten Gewebeklebstoff gemacht, der zur chemisch-mechanischen Verkleinerung des Wundtotraums mit oder ohne Verwendung von Drainagen führt. Prospektive Studien, die zur Identifizierung der effektivsten Strategie führen sollen, sind in der Planung.

Abstract

With an incidence of up to 81 % seroma remains one of the most common sequelae following breast surgery, with about 15 % of these leading to secondary complications such as infection and wound healing disorders. The formation of seroma is multifactorial, based initially on the response of the tissue to mechanical and possibly thermal injury. It is reinforced by exudative (pro)inflammatory processes and “shear forces” and is closely linked to the “dead space” created in the wound area through tissue undermining. The extent of surgery in the chest and axilla is however only partially responsible for seroma formation. Investigations into additional hypothetical risk factors have shown no conclusive results. A range of approaches to avoiding or minimizing seroma formation and related complications in breast surgery was examined. The type of dissection used has been suggested as a factor in some studies, e.g with preliminary efforts by ultrasonic dissectors but no convincing evidence that alternatives to standard electrocautery for dissection are associated with reduced seroma rates. Closure of dead space is widely viewed as important in reducing or avoiding seroma related complications. Use of fibrin-based tissue sealants has not led to relevant improvements. Reports on mechanical closure of the dead space with suturing techniques have demonstrated the efficacy of this approach, but with the drawback of significantly longer operating times and inner scar formation. Use of suction drains to eliminate dead space and avoid or reduce seroma formation has been considered as a “standard of care” by many even though clear evidence supporting the efficacy of drains in this regard is lacking. More recently also preliminary positive results have been obtained with a urethane-based tissue adhesive used for chemical/mechanical closure of the dead space both with and without drain placement. Prospective studies should be performed to identify the most effective strategy.

Schlüsselwörter

Mammachirurgie - Komplikationen - Serome - Gewebeklebstoffe - Totraum

Key words

breast surgery - complication - seroma - surgical adhesive - dead space

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