Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_654_Библиотеки_им_академика_М_И_Перельмана
.pdf
23 Breast Implant Infections
https://t.me/medicina_free
361
23.5 Diagnosis
1. Culture of the draining uid if present (culture should be
done for aerobic, anaerobic as well as atypical
mycobacterium).
2. Ultrasound imaging and guided aspiration of periprosthetic uid. This should be cultured.
3. Blood cultures in patients who have sepsis.
4. Complete blood picture to assess kidney and lung function along with a complete blood picture.
5. In delayed breast swelling, aspirated uid should be
assessed for cytology and immunohistochemistry for
malignancy.
6. If explantation of implant is considered, then the tissue
taken from the capsule as well as from the periprosthetic
area should be cultured.
Cultures for atypical mycobacterium are reviewed at
6weeks, 12weeks, and 18weeks.
23.6 Management (Fig.23.3)
1. The rst step in a patient having signs of inammation
(grade 1) is to start them on broad spectrum antibiotics
which can cover Gram-positive as well as Gram-negative
organisms. There are no established guidelines for
starting anti-microbial treatment and usually specic
antibiotics are started as soon as the culture report is
available. Ultrasound guided uid aspiration should be
done with culture and sensitivity.
2. Patient is monitored every day to check for signs of
improvement. If these signs are present, then the antibiotic is continued for 7–14days.
3. If there are no signs of improvement or the patient has
grade 2–7 infection, then evacuation of the collection, tissue culture, explantation as well replacement of the
implant at a later date should be considered.
4. Salvaging of the implant (may be replacing one implant
with another at the same time) can be considered if there
Fig. 23.3 A owchart published by Washer and Gutowski (2012) is very relevant with regard to the treatment protocol for infections secondary
to breast implant placement
362
ab
https://t.me/medicina_free
M. Thomas and J. D’silva
is limited cellulitis and peri-implant collection. Implants
have been successfully salvaged by cleaning the implant
pocket, antibiotic solution lavage of the pocket, replacement of the implant, and 6weeks of systemic antibiotic
therapy (Laveaux etal. 2009).
5. If the infection is well encapsulated, then in Toto removal
of the implant with its intracapsular pus bag is the best
treatment choice. Another implant can immediately be
placed in the same or another pocket. “Device salvage”
means the continued presence of a prosthetic device after
surgical intervention, though not necessarily retention of
the original device. The different techniques used to
undertake device salvage include antibiotics, debridement, capsulectomy, change of implant position, pulse
lavage, and/or use of a muscle ap if coverage required as
in reconstruction.
23.7 Our Protocol andStep by Step
Treatment Procedure
1. IV or oral broad-spectrum antibiotics: Hospital admission and IV antibiotics have to be started in consultation
with the microbiologist. We usually start a combination
of amoxycillin with clavulanic acid and metronidazole to
cover the anaerobic infections.
2. If the decision has been taken to remove the implant, then
the procedure is scheduled under anaesthesia. Various
steps of the procedure based on the patient’s clinical presentation are shown below.
(a) Acute unilateral or bilateral breast enlargement
(Fig.23.4).
It usually starts with an ultrasound guided culture
analysis of the peri-implant uid. The uid at the
time is completely aspirated protecting the implant
and the patient is placed on antibiotics based on the
culture report. Decision to explant is taken once
there is no response to the antibiotics or the collection recurs after the full course of antibiotics is
completed.
(b) Chronic infection which waxes and wanes under
antibiotic treatment and there are occassional signs
of celluilitis (Fig.23.5).
(c) Management of an exposed breast implant secondary
to infection (Fig.23.6).
(d) Management of an implant with localized collection
with no signs of infection or inammation (Fig.23.7).
Fig. 23.4 (a) Unilateral breast enlargement 2 weeks after surgery.
Only sign of anything abnormal is the breast asymmetry with the left
signicantly larger than the right. (b) Patient underwent ultrasound
guided aspiration with the uid being sent for culture sensitivity. The
uid was completely aspirated. (c, d) 3months after the initial aspiration and treatment with culture sensitive antibiotic (Staphylococcus sp.)
patient represented with obvious signs of infection on the left breast
with imminent exposure at the suture line. Patient now also had systemic signs of infection. (e, f) The implant pocket was opened, implant
was removed, and the abdominal sponge was used to clean the implant
cavity. Fat cells as well as tissue was found adherant to the sponge
which was also found adherant to the implant surface. These tissue
fragments along with a segment of the capsule an dsurrounding tissue
were sent for microbiology examination which included aerobic, anaerobic, and atypical mycobacteris infection. Both implants were removed,
pocket is washed with a combination of povidone iodine solution 5%
and 50% diluted hydrogen peroxide solution and the left pocket was
closed over a drain. Atypical mycobacterial infection belonging to the
subspecies M. fortuitum and M. chelonae was found to be the culprit
for the infection. (g) 2weeks after B/L explantation. (h) Re-implantation
using smooth silicone gel implant was undertaken after treatment of
atypical mycobacterium for 3months and the cool down period with no
infection for 3months according to the Mumbai protocol
gh
cd
ef
23 Breast Implant Infections
https://t.me/medicina_free
363
Fig. 23.4 (continued)
364
bc
https://t.me/medicina_free
M. Thomas and J. D’silva
a
Fig. 23.5
this 40-year-old lady who had undergone breast augmentation 10years.
ago. There are signs of inammation at the NAC even though the
implant has been placed through an inframammary incision. (b) The
right breast looks signicantly larger than the left. (c–e) Inframammary
incision was made and pus deposit was seen in the subcutaneous pocket
which extended into the implant pocket which was opened. 200cc of
pus was drained and the implant was removed. Pus and tissue fragments
(a) Unilateral breast enlargement which has been troubling
along with a segment of the capsule and surrounding tissue were sent
for microbiology examination which included aerobic, anaerobic, and
atypical mycobacterial infection. Both implants were removed, pocket
is washed with a combination of povidone iodine solution 5% and 50%
diluted hydrogen peroxide solution and the right pocket was closed over
a drain. The culture was found to be sterile. (f) 2years after B/L explantation the area has healed well with no repeat infections. Broad spectrum antibiotics were used for only 2weeks
23 Breast Implant Infections
https://t.me/medicina_free
365
d
e
f
Fig. 23.5 (continued)
366
ab
cd
ef
https://t.me/medicina_free
M. Thomas and J. D’silva
Fig. 23.6 (a) Unilateral exposed breast implant in this 42-year-old
lady who had undergone breast augmentation 10years ago. It started
with a small infection like a boil 3months ago which burst due to abrasion with the underwire bra. There was a small amount of watery discharge after which the implant got exposed to the present level. There
are minimal signs of inammation at the edges. (b) The right breast
inframammary incision is almost completely opened. (c) The implant
has been removed and the pocket is washed with a combination of povi-
done iodine solution 5% and 50% diluted hydrogen peroxide solution.
(d) Both implants were removed and the edges of the incision are
excised on the right side. (e) Tissue was sent for culture and the right
pocket was closed over a dependent corrugated drain. The culture was
found to be sterile. (f) 2 weeks after B/L explantation the area has
healed well with no repeat infections. Broad spectrum antibiotics were
used for only 1week
23 Breast Implant Infections
https://t.me/medicina_free
a
367
b
Fig. 23.7
had undergone breast augmentation 5 years ago. She got the periimplant collection twice over the years. There were no signs of inammation but only a gradual enlargement of the right breast which a few
times regressed on its own. Ultrasound and MRI scans did show collection in the right peri-implant area. (b) The right breast inframammary
incision was opened and the implant was removed. There was straw
coloured uid in the pocket but the capsule was thick and leathery.
Doubting the presence of ALCL, a complete capsulectomy was per-
(a) Unilateral chronic swelling in this 50-year-old lady who
c
formed. (c) After complete capsulectomy, the pocket is washed with a
combination of povidone iodine solution 5% and 50% diluted hydrogen
peroxide solution. (d) Replacement of the implant was made in the subpectoral plane (changed from subglandular to subpectoral). Tissue and
capsule were sent for histopathology as well as culture and the right
pocket was closed after haemostasis. The culture was found to be of
streptococcus epidermidis which was sensitive to Cephalosporins. (e)
2months after Implant salvage the area has healed well with no repeat
infections
368
https://t.me/medicina_free
M. Thomas and J. D’silva
d
Fig. 23.7 (continued)
23.8 Mumbai Protocol forAntibiotic
Coverage inAtypical Mycobacterial
Infection
Once the microscopic examination of the uid shows acid
fast bacilli (Ziehl Neelsen stain), atypical mycobacterium
infection should at the top of the list in the surgeon’s mind.
The following antibiotics are suggested:
1. Linezolid: This oxazolidinone is highly effective
against a range of organisms including Gram-positive,
Gram- negative and many atypical organisms including
Legionella pneumophila, Mycoplasma pneumoniae,
and Chlamydia pneumoniae. It is also effective against
several rapidly growing mycobacteria, including
Mycobacterium fortuitum, Mycobacterium chelonae,
and Mycobacterium abscessus (Wallace etal. 2001).
The dosage is 600mg PO/IV daily with expected side
effects to be myelosuppression, peripheral neuropathy,
serotonin syndrome. Vitamin B6 is considered helpful.
Check CBC count with differential count weekly for
2weeks, then twice weekly after that till the duration
of treatment. Minimum duration of treatment is
3months.
2. Gatioxacin: fourth generation ouroquinolone—400mg
once a day for 2–4weeks. Other quinolones can be used
based on the culture report. Side effects may include ten-
e
dinitis, tendon rupture, peripheral neuropathy, CNS
effects, QTc prolongation (rate corrected QT interval).
Consider ECG monitoring if additional risk factors
present.
3. Clarithromycin: It is a type of macrolide which has now
become the rst line of treatment for atypical mycobacterial infection. 500mg twice daily is administered initially
for 2–4 weeks following the culture report. It can be
safely administered for 3months. The usual side effects
are gastrointestinal. Rarely QTc prolongation and/or ototoxicity may be present. Consider ECG monitoring if
additional risk factors present. Audiograms at baseline,
1month, and then every 3months.
4. Amikacin: This drug is used if a patient is hypersensitive
to one of the medications above or the infecting organism
is resistant to the above drugs. 15mg/kg Monday–Friday
or 15–25 mg alternate days for 3 weeks followed by
weekly intramuscular injections. Consider starting with
8–10mg/kg per day for the elderly and those with mild
renal impairment and titrate upward to Cmax.
Nephrotoxicity, ototoxicity are the possible side effects.
Once therapeutic, continue with weekly drug trough and
creatinine levels. Baseline and monthly audiograms.
5. Antitubercular drugs such as isoniazid, rifampicin, and
ethambutol are also effective. Cephalosporins are also
effective in the injectable form. These have to be tested
for culture and then administered.
23 Breast Implant Infections
https://t.me/medicina_free
369
23.9 Infection Risk Reduction inSurgery
(Barr etal. 2016)
23.9.1 Preoperative Factors
23.9.1.1 Surgical Team andOperating
Environment
Every member of the surgical team should be adequately
gowned and prepared to minimize contamination to the surgical eld. This includes the concealment of as much facial
hair as possible, including face shields to prevent eyebrow
dandruff from falling onto the patient. If possible, staff
should use disposable gowns and drapes in implant-based
breast reconstruction or cosmetic procedure.
23.9.1.2 Perioperative Antibiotics
• Antibiotic choice is rst-generation cephalosporin, with
clindamycin in β-lactam antibiotic-sensitive patients.
• Known carriers of MRSA or areas where MRSA is preva-
lent should be given intravenous vancomycin
perioperative.
23.9.1.3 Preoperative Planning
• Adequate preoperative planning to assess amount of tis-
sue cover as well as adequacy of skin laxity to cover the
Implant.
• Use standard protocols to reduce surgery duration whether
for aesthetic procedure or reconstructive.
• Smooth, round silicone implants/expanders are the best
choice to reduce the risk of infection as they reduce the
chances of having a biolm.
• Fill the expander to only half its capacity so that there is
no undue tension on the skin aps.
• If the vascularity of the aps is doubtful or there is inad-
equate muscle cover, consider using cutaneous or myocutaneous aps for cover.
23.9.2 Intraoperative Factors
• Topical mupirocin and daily chlorhexidine body scrub for
5days in people who may be MRSA positive.
23.9.2.2 Pocket Preparation forAesthetic
Augmentation or withMastectomy
• Choosing the right incision for implant placement or
communication with cancer resecting surgeons for possible incision.
• Minimize trauma to mastectomy skin aps and NAC if a
skin sparing mastectomy is planned.
• Meticulous haemostasis.
• Make a precise implant pocket and prevent bottoming
out.
• Triple-antibiotic or povidone iodine irrigation.
• Use dermal matrix (ADM) only if adequate vascular skin
cover is present else plan on a myo-cutaneous skin ap.
23.9.2.3 Implant Handling andInsertion
• Reduce implant contamination by reducing the number of
hands handing them.
• Use fresh pair of powder-free surgical gloves.
• Clean implant-entry site skin edges with gentamycin or
povidone iodine.
• Minimize implant-exposure time.
• Triple-antibiotic irrigation of implant pocket as well as in
packaging to reduce the electrostatic charge on the
implant shell (50,000 U bacitracin, 80 mg. gentamicin,
1Gm cefazolin in saline).
• “No-touch” insertion technique by using the “Keller
Funnel”.
23.9.2.4 Closure andDrains
• Absolute haemostasis using bipolar cautery.
• Consider placement of drains if there are any chances of
hematoma. Appropriate drain care has to be taken.
• Closure should be undertaken in multiple layers preferably using absorbable monolament sutures.
• Use waterproof dressing to prevent contamination of the
surgical site.
23.9.2.1 Skin Preparation andDraping
• Use chlorhexidine with 95% alcohol or povidone Iodine
5% skin preparation. We also use povidone scrubs on the
NAC complex.
• Use of disposable drapes reduce the chance of inadequate
sterility.
• Use a transparent lm or shield to prevent implant from
contamination by nipple-duct ora.
23.9.2.5 Postoperative Care
• Hospital stay to be considered for intravenous antibiotics
if surgery is extensive or risk of infection is present.
• Avoid potential breast-skin contaminants.
• Remove drain (if placed) at the earliest.
• Prophylactic antibiotics to be given atleast for a week.
More if suture line looks inamed (Figs.23.8 and 23.9).
370
https://t.me/medicina_free
M. Thomas and J. D’silva
a
c
b
d
e
Fig. 23.8 (a, b) 39-year-old lady who had undergone breast augmenta-
tion 7 years ago and then had 2 pregnancies with the younger child
breast feeding for almost 3years. She noticed a small boil like lesion on
the inferior aspect of left breast which was incised by a dermatologist
which exposed the implant. (c) Explantation was done with cleaning of
f
the implant pocket and closure of the incision in 2 layers. (d) 4weeks
after removal of the implant. (e, f) Patient underwent re-implantation on
the left side in a new implant pocket. The old capsule was left intact to
provide extra cover on the implant
Соседние файлы в папке Библиотека им академика М.И. Перельмана