Subinternship Surgery · Year 4 · from Subinternship Surgery

Case 2: Postoperative Fluid Collection and DVT

Patient Presentation

Demographics: 45-year-old female

Chief Complaint: Swelling at surgical site and leg pain POD 5 following mastectomy

History of Present Illness: Ms. Williams underwent a left modified radical mastectomy with axillary lymph node dissection for invasive ductal carcinoma 5 days ago. She was discharged on POD 2 with a Jackson-Pratt drain in place, which has been draining 60-80 mL of serosanguinous fluid daily. Today she noticed increased swelling at the surgical site with fluctuance, and the drain output has decreased to 20 mL. She also reports new left calf pain and swelling that started this morning.

Past Medical History:

  • Breast cancer (newly diagnosed)
  • Obesity (BMI 34)
  • Oral contraceptive use (discontinued 1 week pre-op)
  • No prior VTE

Physical Examination:

  • Vitals: T 37.2C, HR 88, BP 118/72, RR 16
  • Left chest wall: Well-healing mastectomy incision, but notable fluctuant collection medial to the incision measuring approximately 8x6 cm, minimal erythema, no warmth
  • JP drain: In place, minimal output
  • Left lower extremity: 3 cm asymmetric calf swelling compared to right, mild tenderness along the course of the deep veins, no erythema or warmth

Laboratory Studies:

  • WBC: 8,200
  • Hgb: 10.8 g/dL
  • D-dimer: 2.4 mg/L (elevated)

Clinical Questions

  1. What is the most likely diagnosis for the chest wall collection, and how should it be managed?

Diagnosis: Seroma (most likely) vs. Hematoma

Differentiation: | Feature | Seroma | Hematoma | |---------|--------|----------| | Timing | POD 5-14 typical | Usually earlier (POD 0-3) | | Consistency | Fluctuant | May be firm, tense | | Fluid character | Clear/straw-colored | Bloody/dark | | Erythema | Minimal | Variable | | Pain | Mild | Moderate-severe | | Risk procedure | Lymph node dissection | Any surgery |

Management of Seroma: | Size | Management | |------|------------| | Small, asymptomatic | Observation, compression | | Moderate, symptomatic | Aspiration with sterile technique | | Large or recurrent | Serial aspirations, may need drain replacement | | Infected | Drainage + antibiotics |

For this patient:

  1. Aspirate under sterile conditions
  2. Send fluid for culture (to rule out infection)
  3. Apply compression dressing
  4. Warn patient that recurrence is common (may need multiple aspirations)
  1. What is your concern regarding the leg symptoms, and how do you evaluate?

Concern: Deep venous thrombosis (DVT)

VTE Risk Factors in This Patient: | Factor | Risk Level | |--------|------------| | Recent major surgery | High | | Cancer diagnosis | High | | Obesity | Moderate | | Recent OCP use | Moderate | | Immobility post-op | Moderate |

Wells Score for DVT: | Criteria | Points | This Patient | |----------|--------|--------------| | Active cancer | +1 | Yes | | Paralysis/immobilization | +1 | No | | Bedridden >3 days or major surgery within 12 weeks | +1 | Yes | | Localized tenderness along deep veins | +1 | Yes | | Entire leg swollen | +1 | No (calf only) | | Calf swelling >3 cm asymmetry | +1 | Yes | | Pitting edema | +1 | Not specified | | Collateral superficial veins | +1 | No | | Alternative diagnosis more likely | -2 | No | | Total | 4 | DVT likely |

Diagnostic Evaluation:

  • Duplex ultrasound of left lower extremity - First-line test for suspected DVT
  1. The ultrasound confirms an acute DVT in the left popliteal vein. What is the treatment?

DVT Treatment:

| Component | Recommendation | |-----------|----------------| | Anticoagulation | Initiate immediately unless contraindicated | | Agent selection | LMWH, fondaparinux, or DOAC (rivaroxaban, apixaban) | | Duration | Minimum 3 months; extended for cancer-associated VTE | | Monitoring | No routine monitoring needed for LMWH/DOAC | | Ambulation | Encourage early mobilization | | Compression | Graduated compression stockings controversial |

Cancer-Associated Thrombosis Considerations:

  • LMWH traditionally preferred over warfarin
  • DOACs (edoxaban, rivaroxaban) now acceptable per recent trials
  • Longer duration (6 months or while cancer active) recommended
  • Higher recurrence risk

IVC Filter Indications:

  • Absolute contraindication to anticoagulation
  • Recurrent PE despite adequate anticoagulation
  • NOT indicated for this patient
  1. What could have been done to prevent this complication?

VTE Prevention Strategies:

| Intervention | Timing | Notes | |--------------|--------|-------| | Risk stratification | Pre-operative | Caprini score or similar | | Mechanical prophylaxis | Intraoperative and post-op | SCDs, graduated compression | | Pharmacologic prophylaxis | Per protocol | LMWH or UFH based on risk and bleeding risk | | Early ambulation | POD 0-1 | Most important intervention | | Hydration | Perioperative | Avoid dehydration | | Extended prophylaxis | High-risk patients | Cancer surgery: consider 4 weeks LMWH |

This Patient's Risk Profile Warranted:

  • SCDs intraoperatively and until fully ambulatory
  • Pharmacologic prophylaxis with LMWH
  • Given cancer surgery, extended prophylaxis (4 weeks) should have been considered
  • OCP discontinuation pre-op (she did this)

Clinical Image

Image: Post-mastectomy seroma is a common complication following breast surgery with axillary lymph node dissection. Sterile aspiration may be required for large or symptomatic collections, though recurrence is common. Source: Wikimedia Commons.

Image Attribution: Surgical wound care. Wikimedia Commons. CC BY-SA 3.0. URL: https://commons.wikimedia.org/wiki/File:Wound_healing_phases.png

Summary Points

  1. SSI Classification: Superficial (skin/subcutaneous), deep incisional (fascia/muscle), and organ/space - management differs for each depth
  1. SSI Management: Open the wound, explore to determine depth, culture, debride necrotic tissue, pack with moist gauze, and start appropriate antibiotics
  1. Dehiscence Risk Factors: Obesity, diabetes, infection, malnutrition, smoking, emergency surgery, wound classification, and technical factors
  1. Evisceration Emergency: Do NOT push bowel back; cover with sterile saline-soaked gauze, position supine with knees flexed, and prepare for emergent OR
  1. Seroma Management: Small collections can be observed; larger ones require aspiration with sterile technique; recurrence is common
  1. DVT Evaluation: Use Wells score to stratify probability; duplex ultrasound is the first-line diagnostic test
  1. Cancer-Associated VTE: Higher risk of recurrence; extended anticoagulation recommended; LMWH or DOAC preferred over warfarin
  1. VTE Prevention: Combines risk stratification, mechanical prophylaxis, pharmacologic prophylaxis, and early ambulation; extended prophylaxis for high-risk cancer surgery

All cases for this lecture as Markdown