Modified Frailty Index and Albumin-Fibrinogen Ratio Predicts Postoperative Seroma After Laparoscopic TAPP.

Background: Postoperative seroma is the most common minor complication after inguinal hernia repair surgery and can have negative consequences. The objective of this study was to identify potential risk factors for postoperative seroma. Methods: This study consecutively included 354 elderly patients with inguinal hernia who underwent laparoscopic Transabdominal preperitoneal Patch Plasty (TAPP). Seroma diagnosis was conducted by the same experienced surgeon based on the physical examinations combined with ultrasound. Risk factors for seroma were identified through univariate analysis and subsequently included in the binary multivariate logistic regression model. Results: A total of 40 patients experienced postoperative complications of seroma, with an incidence rate of 11.3% (40/354). The binary logistic regression analysis revealed that obesity (OR: 2.98, 95% CI: 1.20-7.41, P = 0.018), disease duration ≥ 4.5 years (OR: 4.88, 95% CI: 2.14-11.18, P < 0.001), albumin-fibrinogen ratio (AFR) level < 9.25 (OR: 6.13, 95% CI: 2.00-18.76, P = 0.001), and modified frailty index (mFI) score ≥ 0.225 (OR: 6.38, 95% CI: 2.69-15.10, P < 0.001) were four independent risk factors for postoperative seroma. Conclusion: Obesity, prolonged disease duration, decreased AFR level, and increased mFI score independently predict postoperative seroma after laparoscopic TAPP.

Overlapping stent insertion for a treatment-resistant seroma after arteriovenous fistulation using prosthetic grafts.

An arteriovenous fistula was required for permanent vascular access in a patient undergoing hemodialysis due to progressive chronic kidney disease associated with short bowel syndrome. In the present report, we discuss the case of a patient who underwent arteriovenous grafting because there was no proper native vein as a route, following which a seroma developed near the arterial anastomosis. Despite several surgical treatments, seroma not only recurred but also affected dialysis by compressing the graft. A stent was inserted into the graft to withstand the pressure from the seroma, and because one stent could not withstand the pressure, the stent overlapped where it received the most compression. Since then, the patency of graft has been well maintained for more than 2 years. Increasing the radial force of overlapping stents would be an alternative plan to help solve the problematic repeated compressible seroma despite multiple surgical treatments.

Does the Use of BioZorb® Result in Smaller Breast Seroma Volume?

AIM: To evaluate the impact of BioZorb®, a 3D-bioabsorbable marker, on the tumor-bed boost volume and dosimetric parameters in adaptive boost planning for breast cancer. PATIENTS AND METHODS: Records were reviewed for 51 breast-cancer patients who underwent breast-conserving surgery and adjuvant whole-breast irradiation between January 2017 and October 2018. Changes in lumpectomy boost volume (LBV), doses to organs at risk, toxicity and cosmesis were compared between patients with and without BioZorb® Chi-square test and paired and independent t-tests were used for comparisons of variables. RESULTS: Median follow-up was 35.5 months. Mean LBV on initial CT (LBV1; 32.2 vs. 33.8 cc, p=0.74) and on boost computed tomography (CT) (LBV2; 25.3 vs. 24.8 cc, p=0.87) were similar with and without BioZorb® The mean decrease from LBV1 to LBV2 was 9.0 cc and 6.8 cc with and without BioZorb®, respectively (p=0.42). LBV1 was significantly positively correlated with a 20% reduction in LBV (p=0.02). Mean heart and lung doses on adaptive boost planning CT were slightly lower compared to initial planning CT in both groups. Acute breast pain was reported in 18/51 patients, 9 of whom had BioZorb® (p=0.24). Grade-2 pain was reported in 5/51 patients, 3 of whom had BioZorb® (p=0.11). Excellent or good cosmesis was reported in 36/41 patients. Fair cosmesis was reported in 5/41 patients, of whom 2 had BioZorb® (p=0.64). CONCLUSION: BioZorb® placement does not impact the tumor-bed boost volume nor the variation of seroma volume within the period of treatment. More data and longer follow-up are needed to identify a measurable clinical impact of BioZorb® placement.

Perigraft seroma after total aortic arch replacement using Triplex graft.

A 42-year-old gentleman underwent total aortic arch replacement with Triplex graft (Terumo corporation, Tokyo, Japan) for acute type A dissection. Sixteen months later, a computed tomography revealed a rapidly enlarging low-density area around the graft, with no contrast enhancement. The area was compressing the mediastinal structures, such as the superior vena cava and right pulmonary artery. Suspecting lymphorrhea or perigraft seroma (PGS), surgical drainage was performed. Although fluid accumulation around the graft was cloudy and yellowish, Gram stain was negative. A fatty preparation was administered from the nasogastric tube, demonstrating no leakage of chyle. Intraoperative lymphangiography with indocyanine green also showed no lymphatic leak. Therefore, PGS was suspected. Fibrin glue was applied to the graft and the surgery was completed. PGS drainage after arch replacement, especially with Triplex graft, is extremely rare. We discuss the strategies of diagnosis and treatment for this uncommon complication after aortic surgery.

Applications of Ultrasound in the Postoperative Period: A Review.

BACKGROUND: Recent advances in ultrasound technology have further increased its potential for routine use by plastic and reconstructive surgeons. METHODS: An extensive literature review was performed to determine the most common applications of ultrasound in the postoperative care of plastic and reconstructive surgery patients. RESULTS: In contrast with other available imaging modalities, ultrasound is cost-effective, rapid to obtain, eliminates the need for ionizing radiation or intravenous contrast, and has virtually no contraindications. In addition to its diagnostic capabilities, ultrasound can also be used to facilitate treatment of common postoperative concerns conveniently at the bedside or in an office setting. CONCLUSION: This article presents a review of the current applications of ultrasound imaging in the postoperative care of plastic and reconstructive surgery patients, including free flap monitoring following microsurgery, diagnosis and treatment of hematoma and seroma, including those associated with BIA-ALCL, and breast implant surveillance.

[Breast implant-associated anaplastic large cell lymphoma].

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a serious complication in patients with breast implants. In this case report, a 38-year-old woman who was diagnosed with BIA-ALCL presented with seroma in her left breast eight years after her breast implantation surgery. The purpose of this case report is to draw attention to the fact that "late-onset" seroma in patients with breast implants can be a sign of malignancy. A multidisciplinary approach in the diagnosis and treatment of these patients is important. Manifestations, investigation and management of the disease are reviewed.

Breast implant seroma: A SARS-CoV-2 mRNA vaccine side effect.

Fluid collection surrounding breast implants, called seroma, is a frequent issue that has diverse etiologies. We describe a 48-year-old woman with an acute onset of bilateral breast swelling occurring 5 years after aesthetic surgery and 10 days after a second SARS-CoV-2 mRNA vaccine dose. At breast ultrasound, we found an abundant bilateral peri-implant seroma. Our patient noticed symptom improvement 48 h after nonsteroidal anti-inflammatory drug treatment, complete disappearance of symptoms after 10 days with seroma disappearance documented by ultrasound. We hypothesized a breast implant seroma as post-SARS-CoV-2 mRNA vaccine side effect, as different other diagnosis had been excluded.

Chronic Rhomboid Origin Tear with Seroma: An Unusual Cause of Winging Scapula: A Case Report.

CASE: We present a case of a patient who sustained a rhomboid major origin tear with subsequent seroma formation. The rhomboid major origin was reattached using an Achilles tendon allograft to supplement the repair, and the seroma wall was excised. We were able to alleviate the patient's pain and improve his shoulder function. We present our surgical technique. CONCLUSION: Scapular winging is most often attributed to neurogenic causes, but the goal of this case report is to help orthopaedic surgeons realize that scapular winging is not only a nerve issue but can result from an acute muscle tear.

Chronic Persisting Hematoma: Report of a Case and Literature Review.

The authors present a unique case of chronic persisting hematoma formation at the site of a remote congenital melanocytic nevus excision with tissue expander reconstruction. Similarities between chronic persisting hematoma and chronic encapsulated seroma are addressed to provide guidance on the appropriate workup and management for the plastic surgeon. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

DE-MR simulation imaging for prone radiotherapy after breast-conserving surgery: assessing its application in lumpectomy cavity delineation based on deformable image registration.

BACKGROUND: The application of delayed-enhancement magnetic resonance (DE-MR) simulation imaging in lumpectomy cavity (LC) delineation for prone radiotherapy in patients with an invisible seroma or a low seroma clarity score (SCS) after breast-conserving surgery (BCS) based on deformable image registration (DIR) was assessed. METHODS: Twenty-six patients who were suitable for radiotherapy in prone positions after BCS were enrolled, and both computed tomography (CT) and DE-MR simulation scans were acquired. The LC delineated based on titanium surgical clips on CT images was denoted as LCCT. The LC delineated based on the signal of cavity boundaries on fat-suppressed T2-weighted imaging (T2WI) and multiphase delayed-enhancement T1-weighted imaging (DE-T1WI), which was performed at 2 min, 5 min and 10 min postinjection, were denoted as LCT2, LC2T1, LC5T1 and LC10T1, respectively. Afterwards, DIR was performed to compare the volumes and locations of the LCs with MIM software. The generalized conformity index (CIgen) of inter (intra) observer (Inter-CIgen and Intra-CIgen) was also used to explore the inter(intra) observer variation for LC delineation on each image modality. RESULTS: LCCT-LC10T1 provided the best conformal index (CI) and degree of inclusion (DI), increasing by 2.08% and 4.48% compared to LCCT-LCT2, 11.36% and 2.94% for LCCT-LC2T1, and 8.89% and 7.69% for LC5T1-LCCT, respectively. The center of mass (COM) of LCCT-LC10T1 decreased by 17.86%, 6.12% and 13.21% compared with that of LCCT-LCT2, LCCT-LC2T1 and LCCT-LC5T1, respectively. The agreement of LC delineation was strongest for 10th min DE-TIWI (coefficient of variation, COV = 2.30%, Inter-CIgen = 87.06%, Intra-CIgen = 92.64%). CONCLUSION: For patients with a low SCS (SCS ≤ 2) after BCS, it is feasible to contour the LC based on prone DE-MR simulation images. Furthermore, the LC derived from prone DE-T1WI at 10 min was found to be most similar to that derived from prone CT simulation scans using titanium surgical clips regardless of the volume and location of the LC. Inter (intra) variability was minimal for the delineation of the LC based on 10th min DE-TIWI.

MRI of the Morel-Lavallée lesion - a case series.

INTRODUCTION: The aim of the study was to review the appearances of Morel-Lavallée (ML) lesions on magnetic resonance imaging (MRI). PATIENTS AND METHODS: 14 patients diagnosed with the ML lesion on MRI were analysed retrospectively (mean age = 35 years). Mechanism of injury, time frame from injury to MRI, location, shape, T1 and proton-density fat-suppression (PDFS) signal intensity (SI), presence of a (pseudo)capsule, septations or nodules within the collection, mass effect and fluid-fluid levels were analyzed. The Mellado and Bencardino classification was utilized to classify the lesions. RESULTS: In most cases, mechanism of injury was distortion. Mean time frame between the injury and MRI was 17 days. Lesions were located around the knee in 9 patients and in the peritrochanteric region in 5 patients. Collections were fusiform in 12 patients and oval in 2 patients. 9 collections were T1 hypointense and PDFS hyperintense. 4 collections had intermediate T1 and high PDFS SI. 1 collection had intermediate T1 and PDFS SI. (Pseudo)capsule was noted in 3 cases. Septations or nodules were found in 4 cases. According to the Mellado and Bencardino, collections were classified as seroma (type 1) in 9, subacute hematoma (type 2) in 1 and chronic organizing hematoma (type 3) in 4 cases. CONCLUSIONS: Characteristic features of ML lesion include a fusiform fluid collection between the subcutaneous fat and the underlying fascia after shearing injury. Six types can be differentiated on MRI, with the seroma, the subacute hematoma and the chronic organizing hematoma being the commonest.

The Potential Relation Between polytetrafluoroethylene Grafts after Open Reconstructions for Abdominal Aortic Aneurysm and Perigraft Seromas.

BACKGROUND: The presence of sac enlargement after abdominal aortic aneurysm (AAA) open repair, a condition usually called perigraft seroma (PGS), nearly always has a benign behavior. Some theories implicated for PGS formation include coagulation abnormalities, fibroblast inhibition, low-grade infection, or improper graft handling. METHODS: This is a retrospective study including patients treated for AAA in 2 academic vascular surgery departments from 2007 to 2014, where 1 center preferably used polytetrafluoroethylene (PTFE) grafts whereas the preference of other center was mostly Dacron graft. The definition of PGS was conceived as a fluid collection around the graft on CT scan imaging with a radiodensity ≤25 Hounsfield units, reaching at least 30 mm in diameter and beyond the third postoperative month. Analysis was performed between patients with and without PGS. RESULTS: Seventy-eight patients met the inclusion criteria: 42 received Dacron and 36 PTFE grafts. Twenty-three (29.5%) patients accomplished the PGS diagnosis. Having a PTFE graft was the strongest factor for PGS formation on multivariate analysis. The medium seroma size was 42 mm (range, 30-90.6 mm) and the mean time from AAA repair to PGS detection was 26 months (range, 4-106 months). Three patients of the 23 with PGS required surgical repair, all of them were successfully treated: 2 by endovascular means and the remaining with explantation and Dacron reconstruction. CONCLUSIONS: PGS formation is not an unusual complication after open reconstructions for AAA treatment. This is especially true for PTFE grafts, and thus, closer follow-up is warranted if using this material. Treatment is clearly needed when symptoms appear; however, preventive strategies with either endovascular relining or reopen reconstructions require an individual approach counterbalancing benefits versus risk of the procedures.

Endovascular relining of a Dacron graft for refractory perigraft seroma.

Although perigraft seroma (PGS) is a well-known complication of vascular surgery, optimal therapy has not yet been established. A 90-year-old patient underwent a bypass from the right subclavian artery to the left carotid and subclavian arteries for debranching thoracic endovascular aortic repair. Four years post-surgery, computed tomography revealed PGS at the anastomosis site. Percutaneous needle aspiration and surgical drainage were ineffective in treating PGS. We performed a relining procedure using covered stents for the bypass graft that resolved the PGS. This procedure is minimally invasive, avoids graft excision, and can be especially valuable for elderly patients.

Periprosthetic seroma occurrence after femoropopliteal bypass grafting: Surgical management after failure of non-surgical measures in relieving symptoms.

OBJECTIVE: Periprosthetic seroma is a rare complication of femoropopliteal bypass grafting. Periprosthetic seroma can be defined as the collection of non-infected serous fluid around a prosthetic arterial graft. There is a dearth of literature on how to manage periprosthetic seroma occurrence after femoropopliteal bypass especially in patients whose symptoms do not improve with typical conservative measures.Method/Results: This report highlights the case of a 70-year-old patient who had a femoropopliteal bypass using a 6 mm Propaten graft for peripheral arterial disease. The patient subsequently presented with leg edema. Leg ultrasound and computed tomography arteriogram showed a periprosthetic seroma with a patent graft. Patient was initially managed conservatively and semi-conservatively and ultimately with aggressive therapy utilizing exploration and surgical resection of the seroma capsule. CONCLUSION: Only surgical resection of the seroma capsule produced definitive resolution of the seroma and symptoms. Thigh exploration and surgical resection can be considered as part of the management modalities of periprosthetic seroma occurring after femoropopliteal bypass especially in patients who do not respond to typical conservative measures such as elevation, compression stockings, and diuretics.

Contribution of Magnetic Resonance Imaging in Determining Lumpectomy Cavity in Breast Radiotherapy.

BACKGROUND: Accurate localization of the lumpectomy cavity is important for breast cancer radiotherapy after breast-conserving surgery (BCS), but the LC localization based on CT is often difficult to delineate accurately. The study aimed to compare CT-defined LC planning to MRI-defined findings in the supine position for higher soft-tissue resolution of MRI. METHODS: Fifty-nine breast cancer patients underwent radiotherapy CT planning in supine position followed by MR imaging on the same day. LC was contoured by the radiologist and radiation oncologist together by CT and MRI separately. T2 weighted MR images and tomography findings were combined and the LC volume, mean diameter and the longest axis length were measured after contouring. Subsequently, patients were divided into two groups according to seroma in LC and the above-mentioned parameters were compared. RESULTS: We did not find any statistically significant difference in the LC volume, mean diameter and length at the longest axis between CT and MRI but based on the presence or absence of seroma, statistically significant differences were found in the LC volumes and the length at the longest axis of LC volumes. CONCLUSION: We believe that the supine MRI in the same position with CT will be more effective for radiotherapy planning, particularly in patients without a seroma in the surgical cavity.

Systematic analysis of post-treatment soft-tissue edema and seroma on MRI in 177 sarcoma patients.

PURPOSE: To assess post-treatment subcutaneous edema, muscle edema, and seroma in MRI after soft-tissue sarcoma (STS) resection with regard to muscle involvement of STS and therapy. METHODS: In all, 177 patients were included and received 1.5-T MRI follow-up examinations after treatment. Post-treatment changes were classified according to type of therapy (therapy 1-surgery; therapy 2-surgery with radiation therapy) and primary tumor localization in soft tissue (localization 1, subcutaneous tissue; localization 2, muscle involvement). Subcutaneous and muscle edema were divided into three grades: grade 0, absence of edema; grade 1, low-to-moderate edema; and grade 2, high-grade edema. RESULTS: The mean age of the patients was 55.7 ± 18.2 years and the mean volume of the resected primary STS was 321.5 cm3. After therapy 1 of a sarcoma in localization 1, patients significantly more often showed low-grade subcutaneous tissue edema and an absence of muscle edema (p < 0.001) than high-grade edema. The risk for grade 2 subcutaneous tissue and muscle edema significantly increased with a tumor in localization 2 (RR = 2.58, p = 0.016 and RR = 15, p = 0.0065/RR = 2.05 , p = 0.021, respectively) and after therapy 2 (RR = 15, p = 0.0087 and RR = 2.05, p < 0.0001, respectively). Of the patients with sarcoma in localization 2, 88% developed grade 2 muscle edema after therapy 2; 40% of the patients developed post-treatment seroma. The risk for seroma is significantly higher after surgery and radiation therapy than after surgery alone (p < 0.001). CONCLUSION: High-grade postoperative subcutaneous and muscle edema are significantly associated with muscle involvement of primary STS both in patients with and without radiation therapy. The risk for seroma is significantly higher after surgery with additional radiation therapy than after surgery alone.

Diagnostic challenges and potential early indicators of breast periprosthetic anaplastic large cell lymphoma: A case report.

RATIONALE: Anaplastic large T-cell lymphoma (BI-ALCL) is a rare primitive lymphoma described in women with breast implant prostheses, which has been arousing interest in recent years due to its potentially high social impact. The difficult diagnosis associated with the high and increasing number of prosthetic implants worldwide has led to hypothesize an underestimation of the real impact of the disease among prosthesis-bearing women. The aim of this work is to search for specific radiological signs of disease linked to the chronic inflammatory pathogenetic mechanism. PATIENT CONCERNS: This work describes a case of BI-ALCL in an American woman with no personal or family history of cancer, who underwent breast augmentation for esthetic purposes at our Institute. After about 10 years of relative well-being, the patient returned to our Institute with clear evidence of breast asymmetry due to the increase in volume of the right breast which had progressively become larger over a period of 6 months. There was no evidence of palpable axillary lymph nodes or other noteworthy signs. DIAGNOSIS: The ultrasound and magnetic resonance (MR) tests indicated the presence of seroma with amorphous material in the exudate which was confirmed by indirect signs, visible in right breast mammography. Due to suspected cold seroma, an ultrasound-guided needle aspiration was performed for the cytological analysis of the effusion which highlighted the presence of a number of large-sized atypical cells with an irregular nucleus with CD30 immunoreactivity, leucocyte common antigen (CD45) compatible with the BI-ALCL diagnosis. INTERVENTIONS: In our case, a capsulectomy was performed because the disease was limited inside the capsule and periprosthetic seroma. The final histological examination confirmed the stage. LESSONS: The patient is being monitored and shows no signs of recurrence of disease >24 months after surgery. CONCLUSION: A diagnosis of BI-ALCL can be reached using new radiological indicators, such as fibrin, which is clearly visible by MR in the form of nonvascularized debris of amorphous material hypointense in all sequences, free flowing or adhered to the external surface of the prosthesis.

Complicaciones infrecuentes de las prótesis de mama / Uncommon complications of breast prostheses

Los implantes mamarios se asocian a complicaciones frecuentes ampliamente conocidas y estudiadas como la rotura y la contractura capsular. Sin embargo, debido al número cada vez mayor de pacientes portadoras de implantes mamarios, podemos encontrarnos con patología más infrecuente como la presencia de seroma o infección tardía, adenopatías en la cadena mamaria interna, granulomas en la cápsula del implante -que en algunos casos pueden extenderse más allá de la cápsula fibrosa-, tumores desmoides asociados a los implantes y el linfoma anaplásico de células grandes asociado a implantes mamarios. El objetivo de este artículo es revisar las principales complicaciones infrecuentes asociadas a los implantes mamarios y sus hallazgos radiológicos en las diferentes técnicas. Es importante un correcto manejo de esta patología, principalmente del seroma tardío, para diagnosticar precozmente el linfoma anaplásico de células grandes por su mayor transcendencia

Breast implants are associated with well-known common complications that have been widely studied, such as rupture and capsular contraction. However, the increasingly growing number of patients with breast implants has led to the increased likelihood of coming across less common complications; these include seromas or late infection; adenopathies in the internal mammary chain; granulomas in the capsule of the implant, which in some cases can extend beyond the fibrous capsule; desmoid tumors associated with the implants; and breast implant-associated large cell anaplastic lymphoma. This article aims to review the main uncommon complications associated with breast implants and to describe and illustrate their findings in different imaging techniques. Proper management of these complications is important; this is especially true of late seroma and the diagnosis of breast implant-associated large cell anaplastic lymphoma for their repercussions