Compared with drug therapy and surgical management for breast cancer patients, the issue of drain removal seems worthy of investigation and has been neglected by many surgeons. Determining whether the psychological, disease and economic burden on patients and the extra workload on medical staff are caused by seroma or the effects of active exercise after surgery on patients due to a long drain duration is highly important. Previous studies have had difficulty drawing firm conclusions on the timing of drain removal after mastectomy with axillary surgery because early and late drain removal strategies each have their own advantages and disadvantages; thus, more suitable indicators should be selected(Classe et al., 2006; Kelley et al., 2012; Taylor, Rai, Hoar, Brown, & Vishwanath, 2013; Thomson et al., 2013; Thomson et al., 2016). Our team tried to determine the optimal timing based on comprehensive evidence of drainage conditions, postoperative complications, quality of life and healthcare costs, among which the total drain duration and quality of life were first investigated. Through a 3-arm, multicentre randomized clinical trial, we explored whether drain removal on the first day decreased the output to 10 ml, 20 ml or 30 ml/24 h. It appears that 20 ml might be suitable due to its moderate drain duration, total drain duration, and incidence of seroma and improvements in quality of life and relatively low outpatient visit times and related costs.
Consistent with previous reports, when drain removal was performed according to a relatively higher daily drainage volume, drains could be removed early(Andeweg, Schriek, Heisterkamp, & Roukema, 2011; Clegg-Lamptey, Dakubo, & Hodasi, 2007; Gupta, Pate, Varshney, Goddard, & Royle, 2001; Thomson et al., 2013). It was also found that the total drain duration could be shorter as well, which may be because the retained drains encourage drainage by stimulating tissue reactions or by suction(Baas-Vrancken Peeters et al., 2005). It is generally thought that a shorter total drain duration could reduce the workload of medical staff and be favourable for patient activity. However, early drain removal has also been reported to lead to a higher incidence of seroma, which may cause counterproductive results and anxiety as well as patient discomfort(Barwell, Campbell, Watkins, & Teasdale, 1997; Tejler & Aspegren, 1985). Therefore, can the benefits of less drainage time be balanced against the incidence of seroma? We further explored the patient-reported outcomes measured by the EORTC QLQ-C30 and searched for answers from the patients, who have been neglected by most previous studies(Andeweg et al., 2011). We focused on RF, PF and QoL, which were the most likely factors to be affected by drainage. Patients in the 20 ml group exhibited superiority in terms of PF and RF at 2 and 3 weeks after the operation. This is most likely because early drain removal can aid in resuming physical activity and rapid rehabilitation. However, this benefit was not reflected in the 30 ml group. One possible explanation is that the incidence of seroma was too high, and patients needed to reduce their level of physical activity, offsetting the benefits conferred to the patients. QoL was similar in three groups. This could be because the QoL was assessed by physical condition, which was mainly affected by the patient’s breast cancer and their surgical condition.
Advantages were also found in the 20 ml group in terms of outpatient visits and costs. Although the 30 ml group had a shorter total drain duration, the high incidence of seroma resulted in additional outpatient visits and extra associated costs, so their outcomes were equivalent to the 20 ml group. The same trend was identified in previous studies: a shorter drain duration but higher incidence of seroma caused even more outpatient visits(Andeweg et al., 2011; Okada et al., 2015). However, the 10 ml group had the most outpatient visits in the present study, probably because the visits for too-long drainage could not be balanced by seroma treatment. In addition, the outpatient costs were proportional to the number of visits. However, neither of them were significantly different among the three groups.
In terms of complications possibly associated with seroma and drain duration(Andeweg et al., 2011; Devoogdt et al., 2011; Torres Lacomba et al., 2010), there was no significant difference between the 20 ml group and the other two groups. We gave little concern to the length of hospital stay, although a significantly shorter stay was observed for patients with early drain removal in previous reports(Andeweg et al., 2011; Baas-Vrancken Peeters et al., 2005; Dalberg et al., 2004; Droeser et al., 2009; Jain, Sowdi, Anderson, & MacFie, 2004). Patients in China are discharged according to the clinical course and independent of the drain duration.
Altogether, the results of this study indicated that for patients who undergo mastectomy and axillary surgery (whether SLNB or ALND), drains should be removed when the output is less than 20 ml per day, which was found to be the best timing.