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A SNAPshot series of Challenging Wounds Made Easy in Breast Surgery: Case 2- Successful management of complex fistulating idiopathic granulomatous mastitis (IGM) with 3M™ SNAP™ therapy following debridement

Author(s): Jun Xian Jeffrey Hing, Yen Nee Sophia Chua Chi Wei Mok,Su-Ming Tan

Published: 29 September, 2021

Case Study

A SNAPshot series of Challenging Wounds Made Easy in Breast Surgery: Case 2- Successful management of complex fistulating idiopathic granulomatous mastitis (IGM) with 3M™ SNAP™ therapy following debridement

Jeffrey Jun Xian Hing1,3, Chi Wei Mok1,3 Yen Nee Sophia Chua2, Su-Ming Tan1,3

1Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore

2Department of Nursing, Changi General Hospital, Singapore

3Singhealth-Duke NUS Breast Centre

 

*On behalf of Changi General Hospital Breast Centre Breast Care Nurses (BCN): Yen Nee Sophia Chua (Advanced Practice Nurse) Thai Wei Li, Lim Chii Kiang Serene, Tang Ping Sing, Norhidayati Binte Mohd Noor, Christine Joy Manuel, Siti Hajar Binte Mat Nadar

 

Correspondence to:

Jeffrey Jun Xian Hing

Division of Breast Surgery, Department of Surgery, Changi General Hospital, Singapore.

Singhealth Duke-NUS Breast Centre

Email: hing.jun.xian@singhealth.com.sg

 

 

Idiopathic granulomatous mastitis (IGM) is a rare benign chronic inflammatory disease that affects mostly women of childbearing age. Symptoms often include fistula, abscess and a palpable tender mass in the breast. This inflammatory condition is often challenging to manage as it often runs a refractory course. Complete resolution has been reported to take up to 20 months and may involve prolonged steroid, antimicrobial with or without methotrexate use in its process. Surgical excisions generally offer a lower risk of recurrence but have been associated with slower wound healing ranging from 6 months to 14.5 months. This also comes with the additional cost of extensive scarring, unnecessary breast deformation, and costly wound care treatments.

We present a successful management of a complex breast wound following debridement of a multiloculated breast abscess in the setting of fistulating idiopathic granulomatous mastitis. Resolution of fistulation and complete wound healing occurred within a 1 month and 3-month time-frame respectively.

The SNAP therapy is a lightweight innovative system that proves to be safe for breast wounds even around the NAC and is shown to be effective at reducing recovery times. This is also promising as a cost-effective solution at improving outcomes in the management of complex fistulating wounds of idiopathic granulomatous mastitis post debridement.

Introduction

A 27-year-old female foreign domestic helper was admitted on 5th April 2021 with a 5-day history of left breast swelling with discharge. She was a non-smoker, had no history of breastfeeding, and had no other medical condition. On examination, she had a 5 by 5cm area of fluctuant swelling at the left breast 10 o’clock position with surrounding induration. There was an area of complex fistulation measuring about 1 by 1 cm causing discharge. (Fig. 1a) A breast ultrasound identified a large irregular heterogenous hypoechoic area in the upper half of the breast with several tracts extending radially. (Fig. 1c) There were two smaller cystic foci identified separately at the left breast 1 o’clock position. She was counselled for incision and drainage of left breast abscess in view of the complex abscess anatomy and fistulation. Intraoperative finding was that of a 9 by 7 cm multiloculated abscess cavity with separate extension to the 1 o’clock position, requiring undermining of the skin flap to connect to the index cavity and to allow for adequate drainage and flushing. The cavity had an average depth of about 2cm with some areas undermined close to the pectoralis fascia which was concordant with the ultrasound findings.

Her resultant wound measured about 4 by 3 cm with a further undermining in the 6, 10 and 1 o’clock positions. (Fig. 1b) She was discharged on post-operative day 1, with instructions to return to clinic for daily flushing and wound review. Return effluent from the flushing of the wound bed was clear and the wound bed reviewed to be clean by 2nd post-operative day (POD). Histology obtained from intraoperative debridement confirms idiopathic granulomatous mastitis (IGM) with no evidence of acid-fast bacilli, or fungal organisms.

The SNAP therapy was proposed early in the course of recovery in view of the complex anatomy of the abscess cavity and the tendency of IGM to form fistulous tracts when left to recover conservatively. The benefit of the SNAP negative pressure wound therapy system also provided ease of application and maintenance of the wound therapy for the patient and her employer who would otherwise need to return daily for wound review and dressing change at least for the first few weeks. This frequency may decrease to three times a week subsequently. The frequency of the SNAP change is twice a week for two weeks and additional SNAP therapy may not be necessary since wound healing is accelerated. The simplicity of the SNAP therapy system also made it easier for both the patient and employer to accept. The SNAP system is also lightweight compared to other conventional negative pressure therapy system. It utilises specialised springs to generate a preset continuous negative pressure without the use of any electrically powered pump, hence reducing the risk of device malfunction.

Methods

The SNAP therapy was planned for 2 weeks. The first application was done in clinic. Measurement of the various undermined area were determined to cut out a disc of foam. The wound edge including the nipple areola complex (NAC) was outlined with Brava® Strip Paste (Coloplast). The Brava® Strip Paste helps to create a tight seal between the NAC and the baseplate. This also helps avoid leakage, absorb moisture and improve the skin around the wound.  The hydrocolloid stick pad is then applied to the breast covering the NAC without need for additional barrier dressing application. The application is performed under 5 minutes by a single breast care nurse with supervision and minimal assistance from the attending physician. A 60ml canister was used with preset negative pressure of 125mmHg. The patient tolerated well without complaints of pain during application and subsequent removal.  There were no unplanned change of the SNAP canisters or leakage that required reinforcement.

Results

The patient used a total of 4 SNAP canisters, with application starting on 2nd POD and changed every 72hours. The was done on an outpatient basis and concluded on the 16th POD.

The wound was seen to be granulating well with minimal residual cavity at the 12 o’clock position upon removal of the last application. However, there was an interval development of pinpoint discharging sinus at 10 o’clock and another focal induration at 12 o’clock area. These were conservatively managed with oral antibiotics and simple wound dressing. (Fig. 3) She was given appropriate dressing advice with non-stick dressing and she returned for weekly review. By the end of the first month, both the sinus and induration have resolved. She did not require further drainage procedures or admission for intravenous therapy. She remained well and the wound was significantly improved by week 10 of follow-up. There was no evidence of recurrence of IGM at short term follow up.

Figures

Figure 1. Pre- (1a) and post-operative (1b) image of left breast abscess incision and drainage. Final wound measures 4cm in transverse diameter with an underlying cavity of 9cm (ML) by 7cm (SI) by 2cm (AP).

 

Figure 2a) Wound prior to SNAP application

2b) SNAP application with use of Brava Strip Paste to outline nipple areola complex (NAC)-wound interface

2c) Healthy granulating wound base with preserved skin and NAC after 2 weeks of SNAP therapy.

 

 

Figure 3a. Resolving sinus at 9 o’clock, and induration at 12 o’clock treated with antibiotics and dressing at week 4

3b. Resolution of the fistulation and infection by the end of the first month.

3c. Significant wound improvement with contracted scarring by week 10.

Discussion

Idiopathic granulomatous mastitis (IGM) is a rare benign chronic inflammatory disease that affects mostly women of childbearing age. [1] Symptoms often include fistula, abscess and a palpable tender mass in the breast. This inflammatory condition is often challenging to manage as it often runs a refractory course and complete resolution may take 5 to 20 months. [1,2] There is lack of consensus on ideal treatment. While some uncomplicated IGM with a benign self-limiting course may favour a conservative strategy often involving medical therapy with corticosteroids, those with secondary fistula or abscess formation often necessitate surgical excision, abscess drainage or aspiration. [3] This may be followed with a prolonged course of steroids, antimicrobial and/or methotrexate therapy up to 15months and may be associated with various systemic side effects including Cushingnoid appearance, antimicrobial resistance and deranged liver function respectively. [4,5] Surgical excisions generally offer a lower risk of recurrence but have been associated with slower wound healing ranging from 6 months to 14.5 months. [3,6] This also comes with the additional cost of extensive scarring, unnecessary breast deformation, and wound care treatments.

Our case demonstrated a successful management of a complex fistulating IGM with extensive abscess formation. The time to resolution for both infection and fistulation was under 1 month. (Fig 3b). This represents one of the shortest reported timings to resolution for such severe spectrum of the condition. [1,2,3,6] At 3 months, the patient had shown significant epithelialisation (>90%) of the wound with no evidence of recurrence. To date, there are no cost effectiveness analysis study done on wound healing by negative pressure therapy versus secondary intention following wound debridement for IGM. [7] We aim to provide a simple cost comparison between patients on SNAP therapy versus healing by secondary intention with conventional dressing change using Aquacel Ag (ConvaTec, Princeton, NJ) at our institution.  The cost quoted for a 2-week (4 SNAP canisters change) therapy amounted to USD 672 (Singapore Dollars SGD 912). The alternative regime of conventional dressing change would require patients to return to clinic at least 3 times per week and regular dressing change. Given the size of the wound, it would easily require a 10 by 10cm sheet at each dressing change. A conservative estimate of the cost of wound review appointments and wound products incurred would easily amount to an average of SGD 160 per week. This would represent likely cost savings for patients put on SNAP therapy, if the wound was estimated to take more than six weeks to heal by secondary intention process due to its size and extent. This does not take into account the number of patients’ productive hours accrued from the shortened recovery. The perceived high cost for starting patient on SNAP therapy is likely to be offset by the significant reduction in recovery time, reduced frequency of wound dressing change at outpatient clinic, faster return to work, avoidance of additional medical therapy and its associated side effects, although further cost effectiveness analysis study would be required to prove this.

However, there are limitations to the consideration of using the SNAP therapy for such infected wounds. The wound bed should be well vascularised, relatively shallow, and are relatively clean following debridement. The wound should ideally be less than 10 by 10cm and not have exudates more than 80ml over 3 days. [7] Given the proper patient selection, the experience with SNAP therapy application is generally positive with the process being hassle free and well tolerated. There was also little hindrance to the patient’s mobility, shoulder and arm movement due to the lightweight nature of the system, making it ideal for patient profile and wounds of such nature. Lastly, upon completion of the therapy, there is no significant deformity to the natural breast shape or alteration of the appearance, position and sensation of the NAC to suggest complication from the SNAP therapy application.

Conclusion

In summary, the SNAP therapy is a lightweight innovative system that proves to be safe for breast wounds even around the NAC and is shown to be effective at reducing recovery times. This is also promising as a cost-effective solution at improving outcomes in the management of complex fistulating wounds of idiopathic granulomatous mastitis post debridement.

 

Acknowledgement

We would like to thank the support of all the Breast care nurses – Thai Wei Li, Lim Chii Kiang Serene, Tang Ping Sing, Norhidayati Binte Mohd Noor, Christine Joy Manuel, Siti Hajar Binte Mat Nadar at Changi General Hospital Breast Centre for facilitating the care for this patient.

Disclosure

No conflict of interest to declare.

Patient anonymity has been maintained.

The case study submitted to this competition has not been published or submitted elsewhere.

 

 

References

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