Rapid Responses to:

PAPERS: Jorien Bonnema, Anneke M E A van Wersch, Albert N van Geel, Jean F A Pruyn, Paul I M Schmitz, Marinus A Paul, and Theo Wiggers Medical and psychosocial effects of early discharge after surgery for breast cancer: randomised trial BMJ 1998; 316: 1267-1271 [Abstract] [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

My Own Experience with Early Release from Hospital

Sheila Whitlock   (25 April 1998)

Flawed design to answer these questions

A D Purushotham   (18 May 1998)

Maintaining drains after surgery

Gláucia Gondin   (23 July 1998)

My Own Experience with Early Release from Hospital 25 April 1998
Sheila Whitlock City of Edmonton Send response to journal: Re: My Own Experience with Early Release from Hospital	I was diagnosed with Paget's Disease and went through a radical mastectomy in January '98. My surgery was performed about 2 PM on the 14th and I was released at 9 AM on the 15th. only 18 hours later. While I really didn't want a long hospital stay I feel that there was no time to adjust and your head is still in a whirl that what ever instructions you are give going home are not absorbed. If it had been a day or two later my head would have been clearer and I would have retained these instructions. I did have problems with the drain getting plugged and homecare came out three times in one day to assist me in unplugging it. It was scary and upsetting being alone and not knowing exactly what was going on. After about four days things settled and I was fine. I had no problems with infections. In my opinion I think a two to three day stay would be beneficial to the patient. My stay was far too short and may people just couldn't believe it was so short. I am not one to demand a great deal of attention but there are people who do and take up a lot of the staff time over minimal things.
Flawed design to answer these questions 18 May 1998
A D Purushotham, Senior Lecturer in Surgery Western Infirmary, Glasgow, G11 6NT Send response to journal: Re: Flawed design to answer these questions	Editor, While one welcomes randomised trials, the study by Bonnema et al fails to answer the questions they have sought to address. Firstly, the two groups being compared contain a mixed cohort of patients undergoing breast-conserving surgery and modified radical mastectomy. They therefore have made the fundamental assumption that women undergoing both procedures behave exactly the same way in terms of their post-operative complication rate for eg, volume of seroma fluid drainage and suffer the same degree of psychological morbidity. They should have been stricter in their inclusion criteria and only recruited patients who underwent the same surgical procedure. This would have made their results more meaningful. The concept of keeping patients in hospital for 9-12 days post-operatively is archaic. In our practice, which probably reflects the practice in the rest of the UK, the mean post-operative hospital stay is in the region of 4 days with drains being removed on day 5, irrespective of volume of drainage of fluid. One of their aims was to address the complication rate following early discharge. However,in discussion, they state that "the number of patients in this study was too small to detect a difference of 5% in rates of wound complication" and subsequently claim that recruitment of 800 patients, which is what would have been required, would not have been "feasible in this type of research". Why? It is vital that any study examining shorter hospital stay must involve a detailed analysis of costs with the help of a health economist to calculate in-hospital and community costs. This is particularly important for the UK where NHS funding is central. The follow-up period to assess psychological morbidity is too short. At 3 months patients may be undergoing adjuvant therapy, loco-regional radiotherapy and systemic chemotherapy, which add to their morbidity. It is essential that such studies are designed to assess psychological morbidity at completion of treatment to provide a more meaningful result. In this study, a further set of questionnaires to be completed at one year would have been necessary. These issues are currently being addressed in a randomised trail in our institution, funded by the Scottish Office, which will complete recruitment at the end of 1998. Results from this study will hopefully clarify all the issues raised above.
Maintaining drains after surgery 23 July 1998
Gláucia Gondin, time that patients stay wuith the drain Carmela Dutra Maternity Send response to journal: Re: Maintaining drains after surgery	We are from a Mastology Service in Florianópolis, SC, Brazil. After surgery for breast cancer we leave drains in for 10 to 15 days. Patients are discharged on the second postoperative day and checked to ensure that the drain remains patent. Our incidence of seroma is low, but it is hard for patients to stay at home with a high vacuum drainage system. Please tell us your incidence of postoperative seroma and your opinion of removing drains on the fourth day after surgery.