Purulent mastitis

Despite the significant advances that modern medicine has achieved in the treatment and prevention of infections, purulent mastitis continues to be an urgent surgical problem. Long periods of hospitalization, a high percentage of relapses and the consequent need for repeated operations, cases of severe sepsis, poor cosmetic results of treatment continue to accompany this common pathology.

[1], [2], [3]

Causes of the purulent mastitis

Lactational purulent mastitis occurs in 3.5-6.0% of parturient women. More than half of the women it occurs in the first three weeks after childbirth. Purulent mastitis is preceded by lactostasis. If the latter is not allowed within 3-5 days, then one of the clinical forms develops.

The bacteriological picture of lactational purulent mastitis has been studied quite well. In 93,3-95,0% of cases it is caused by golden staphylococcus, detected in monoculture.

Non-lactating purulent mastitis occurs four times less frequently than the lactation mastitis. The reason for its occurrence are:

• trauma of the mammary gland;
• acute purulent-inflammatory and allergic diseases of the skin and subcutaneous tissue of the breast (furuncle, carbuncle, microbial eczema, etc.);
• fibrocystic mastopathy;
• benign tumors of the mammary gland (fibroadenoma, intraductal papilloma, etc.);
• malignant neoplasms of the breast;
• implantation of foreign synthetic materials into the gland tissue;
• specific infectious diseases of the breast (actinomycosis, tuberculosis, syphilis, etc.).

The bacteriological picture of non-lactating purulent mastitis is more diverse. In about 20% of cases, the bacteria of the Enterobacteriaceae family, P. Aeruginosa, as well as non-clostridial anaerobic infection are identified in association with Staphylococcus aureus or enterobacteria.

Among the many classifications of acute purulent mastitis cited in the literature, the most widely cited classification is NN Kanshin (1981).

I. Acute serous.

II. Acute infiltrative.

III. Abscessed purulent mastitis:

1. Apostematous purulent mastitis:
   • limited,
   • diffuse.
2. Abscess of the breast:
   • solitary,
   • multifaceted.
3. Mixed abscessed purulent mastitis.

IV. Phlegmonous purulent mastitis.

V. Necrotizing gangrenous.

Depending on the localization of purulent inflammation, purulent mastitis is distinguished:

• subcutaneous,
• subareolar,
• intramammary,
• retromammaric,
• total.

[4], [5], [6], [7]

Symptoms of the purulent mastitis

Lactation purulent mastitis begins acutely. Usually it passes through the stages of serous and infiltrative form. The mammary gland somewhat increases in volume, there is a hyperemia of the skin above it from barely noticeable to bright. When palpation is defined sharply painful infiltration without clear boundaries, in the center of which a softening focus can be detected. The state of health of a woman suffers significantly. There is a sharp weakness, a violation of sleep, appetite, an increase in body temperature to 38-40 ° C, chills. In the clinical analysis of the blood leukocytosis with neutrophil shift, increased ESR.

Non-lactic purulent mastitis has a more worn out clinic. At the initial stages the picture is determined by the clinic of the underlying disease, to which purulent inflammation of the breast tissue joins. Most often, non-lactational purulent mastitis proceeds as a subareolar abscess.

Forms

Purulent mastitis is divided into two large groups: lactational and non-lactate. They differ in the cause of the disease, in the characteristics of the clinic and in diagnosis, in surgical treatment.

[8], [9], [10], [11], [12]

Diagnostics of the purulent mastitis

Purulent mastitis is diagnosed on the basis of typical symptoms of the inflammatory process and does not cause difficulties. When doubting the diagnosis, the puncture of the mammary gland with a thick needle, at which localization, the depth of purulent destruction, the nature and amount of exudate, is significant help.

In the most difficult cases for diagnosis (for example, apostematous purulent mastitis) to clarify the stage of the inflammatory process and the presence of abscesses, ultrasound of the breast can be used. In the course of the study, the destructive form determines the decrease in the echogenicity of the gland tissue with the formation of hypoechoence zones in the places of purulent contents accumulation, the expansion of the milk ducts, the infiltration of tissues. With non-lactic purulent mastitis, ultrasound helps to detect neoplasms of the breast and other pathologies.

[13], [14]

Treatment of the purulent mastitis

The choice of surgical access depends on the location and extent of the affected tissues. At subarayolar and central intramammary purulent mastitis a paraareolar incision is performed. On a small mammary gland from this same access it is possible to produce a DOT, occupying no more than two quadrants. In the surgical treatment of purulent mastitis, extending to 1-2 upper or medial quadrants, an intramammary form of the upper quadrants is performed by an Angerer radial incision. Access to the lateral quadrants of the mammary gland is produced by an external transitional fold according to Mostkova. With the localization of the inflammation focus in the lower quadrants, with retromammary and total purulent mastitis, the cut of the WHOLE breast is accessed by Hennig in addition to the unsatisfactory cosmetic result, the development of mammoptoza Bardengeuer, proceeding along the lower transitional fold of the breast, is possible. The accesses of Hennig and Rovninsky are not cosmetic, they do not have an advantage over the above mentioned ones, so they are practically not used at present.

The basis of surgical treatment of purulent mastitis is the principle of HOGO. The volume of excision of affected tissues of the breast to this day by many surgeons is decided ambiguously. Some authors prefer sparing methods of treatment for prevention of deformation and disfigurement of the breast, consisting in opening and draining the purulent focus from a small incision with minimal necroctomy or without it at all. Others, often noting the long-term retention of the symptoms of intoxication, the high need for repeated operations, the cases of sepsis, associated with the insufficient volume of removal of the affected tissues and the progression of the process, in our opinion, fairly tend to favor radical HOGO.

The excision of non-viable and infiltrated breast tissue is performed within healthy tissues, before the appearance of capillary bleeding. With non-lactic purulent mastitis on the background of fibrocystic mastopathy, fibroadenomas perform intervention by the type of sectoral resection. In all cases of purulent mastitis, histological examination of the removed tissues is necessary to exclude malignant neoplasm and other diseases of the mammary gland.

In the literature, the question of the application of the primary or primary-delayed suture after radical GOOGO with drainage and flow-aspiration washing of the wound with abscessing form is widely discussed. Noting the advantages of this method and the reduction in the duration of inpatient treatment associated with its use, it should nevertheless be noted that the incidence of wound is quite high, whose statistics in the literature are largely bypassed. According to AP Chadaev (2002), the frequency of wound suppuration after the imposition of the primary suture in the clinic, aimed specifically at treating purulent mastitis, is at least 8.6%. Despite a small percentage of festering, nevertheless it is more safe for wide clinical application to consider an open method of wound management with the subsequent imposition of a primary-delayed or secondary suture. This is due to the fact that clinically it is not always possible to adequately assess the extent of tissue damage by a purulent-inflammatory process and, consequently, to carry out a complete necrectomy. The inevitable formation of secondary necrosis, high contamination of the wound by pathogenic microorganisms increases the risk of recurrence of purulent inflammation after the imposition of the primary suture. An extensive residual cavity formed after radical HOOG is difficult to eliminate. The accumulated exudate or hematoma lead to frequent suppuration of the wound even in conditions that seem to be adequate drainage. Despite the healing of the mammary gland by primary tension, the cosmetic result after surgery with the primary suture usually leaves much to be desired.

Most clinicians adhere to the tactics of two-stage treatment of purulent mastitis. At the first stage we carry out a radical HOGO. The wound is opened with the use of ointments on a water-soluble basis, iodophor solutions or drainage sorbents. When SIRS phenomena and with extensive lesion of the mammary gland, we prescribe antibacterial therapy (oxacillin 1.0 g 4 times a day intramuscularly or cefazolin 2.0 g 3 times intramuscularly). With non-lactic purulent mastitis, empirical antibacterial therapy includes cefazolin + metronidazole or lincomycin (clindamycin), or amoxiclav in monotherapy.

In the course of postoperative treatment, the surgeon has the ability to control the wound process, directing it in the right direction. Over time, the inflammatory changes in the area of the wound are steadily being reduced, its microflora is less than critical, and the cavity is partially filled with granulations.

In the second stage, after 5-10 days, we perform skin plasty of the mammary gland with local tissues. Given that more than 80% of patients with purulent mastitis - women under 40 years of age, the stage of restorative treatment is considered extremely important and necessary for obtaining good cosmetic results.

Dermal plasty is performed according to the method of J. Zoltan. Cut the edges of the skin, the walls and the bottom of the wound, giving it a possible wedge shape convenient for suturing. The wound is drained with a thin through perforated drainage, drained through the contra-perpertures. The residual cavity is eliminated by the imposition of deep seams from the absorbable thread on the atraumatic needle. On the skin impose an intradermal suture. The drainage is connected to the air-aspirator. Necessities of constant washing of a wound at tactics of a two-stage treatment are not present, only aspiration of wound separable is carried out. Drainage is usually removed on the 3rd day. At laktoree the drainage can be in a wound more long period. The intradermal suture is removed for 8-10 days.

Performing skin plasty after the suppression of purulent process can reduce the number of complications to 4.0%. At the same time, the degree of deformation of the mammary gland decreases, the cosmetic result of the intervention increases.

Usually a purulent-inflammatory process affects one of the mammary glands. Two-sided lactational purulent mastitis is rare, in only 6% of cases.

In a number of cases, when there is a flat wound of the mammary gland of small size in the outflow of purulent mastitis, it is sutured tightly, without the use of drainage.

Treatment of severe forms of purulent non-lactative purulent mastitis, which occurs with the participation of anaerobic flora, especially in patients with a history of heaviness, presents significant difficulties. The development of sepsis on the background of an extensive purulent necrotic focus leads to high lethality.