Purulent mastitis

Despite the significant advances that modern medicine has made in the treatment and prevention of infections, purulent mastitis continues to be a pressing surgical problem. Long hospitalization periods, a high percentage of relapses and the associated need for repeated surgeries, cases of severe sepsis, and poor cosmetic results of treatment still accompany this common pathology.

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Causes purulent mastitis

Lactational purulent mastitis occurs in 3.5-6.0% of women in labor. More than half of women experience it in the first three weeks after delivery. Purulent mastitis is preceded by lactostasis. If the latter does not resolve within 3-5 days, 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 Staphylococcus aureus, detected in monoculture.

Non-lactational purulent mastitis occurs 4 times less frequently than lactational mastitis. The causes of its occurrence are:

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

The bacteriological picture of non-lactational purulent mastitis is more diverse. In approximately 20% of cases, bacteria of the Enterobacteriaceae family, P. aeruginosa, as well as non-clostridial anaerobic infection in association with Staphylococcus aureus or Enterobacteria are detected.

Among the many classifications of acute purulent mastitis given in the literature, the most noteworthy is the widespread classification of N. N. Kanshin (1981).

I. Acute serous.

II. Acute infiltrative.

III. Abscessing purulent mastitis:

1. Apostematous purulent mastitis:
   • limited,
   • diffuse.
2. Breast abscess:
   • solitary,
   • multi-cavity.
3. Mixed abscessing purulent mastitis.

IV. Phlegmonous purulent mastitis.

V. Necrotic gangrenous.

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

• subcutaneous,
• subareolar,
• intramammary,
• retromammary,
• total.

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Symptoms purulent mastitis

Lactational purulent mastitis begins acutely. It usually goes through the stages of serous and infiltrative forms. The mammary gland increases in volume somewhat, hyperemia of the skin above it appears from barely noticeable to bright. Palpation reveals a sharply painful infiltrate without clear boundaries, in the center of which a softening focus can be detected. The woman's well-being suffers significantly. There is severe weakness, sleep disturbance, appetite, an increase in body temperature to 38-40 ° C, chills. Leukocytosis with a neutrophilic shift, an increase in ESR are noted in the clinical blood test.

Non-lactational purulent mastitis has a more blurred clinical picture. At the initial stages, the picture is determined by the clinical picture of the underlying disease, to which purulent inflammation of the mammary gland tissue is added. Most often, non-lactational purulent mastitis occurs as a subareolar abscess.

Forms

Purulent mastitis is divided into two large groups: lactational and non-lactational. They differ in the cause of the disease, clinical features and diagnostics, and surgical treatment methods.

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Diagnostics purulent mastitis

Purulent mastitis is diagnosed based on typical symptoms of the inflammatory process and does not cause any difficulties. If the diagnosis is in doubt, a puncture of the mammary gland with a thick needle is of considerable help, which reveals the localization, depth of purulent destruction, nature and amount of exudate.

In the most difficult to diagnose cases (for example, apostematous purulent mastitis), ultrasound of the mammary gland allows to clarify the stage of the inflammatory process and the presence of abscess formation. During the study, in the destructive form, a decrease in the echogenicity of the gland tissue is determined with the formation of hypoechogenic zones in places where purulent contents accumulate, expansion of the milk ducts, and tissue infiltration. In non-lactational purulent mastitis, ultrasound helps to identify neoplasms of the mammary gland and other pathologies.

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Treatment purulent mastitis

The choice of surgical approach depends on the location and volume of the affected tissues. In case of subareolar and central intramammary purulent mastitis, a paraareolar incision is performed. On a small mammary gland, a CGO can be performed from the same approach, occupying no more than two quadrants. In surgical treatment of purulent mastitis spreading to 1-2 upper or medial quadrants, with the intramammary form of the upper quadrants, a radial incision is made according to Angerer. Access to the lateral quadrants of the mammary gland is made along the external transitional fold according to Mostkov. If the inflammation focus is localized in the lower quadrants, with retromammary and total purulent mastitis, a CGO incision of the mammary gland is performed using the Hennig approach; in addition to an unsatisfactory cosmetic result, the development of Bardengeuer mammoptosis is possible, running along the lower transitional fold of the mammary gland. The Hennig and Rovninsky approaches are not cosmetic, they have no advantage over the above mentioned ones, therefore they are practically not used at present.

The surgical treatment of purulent mastitis is based on the principle of CHO. The volume of excision of affected tissues of the mammary gland is still decided ambiguously by many surgeons. Some authors prefer gentle methods of treatment to prevent deformation and disfigurement of the mammary gland, consisting of opening and draining the purulent focus from a small incision with minimal necrectomy or without it at all. Others, often noting with such tactics the long-term persistence of intoxication symptoms, a high need for repeated operations, cases of sepsis associated with insufficient volume of removal of affected tissues and progression of the process, in our opinion, rightly lean in favor of radical CHO.

Excision of non-viable and infiltrated tissues of the mammary gland is performed within the healthy tissues, before capillary bleeding occurs. In case of non-lactational purulent mastitis against the background of fibrocystic mastopathy, fibroadenomas, an intervention is performed by the type of sectoral resection. In all cases of purulent mastitis, it is necessary to perform a histological examination of the removed tissues to exclude malignant neoplasms and other diseases of the mammary gland.

The issue of using primary or primary-delayed suturing after radical CHO with drainage and flow-aspiration lavage of the wound in the abscessing form is widely discussed in the literature. Noting the advantages of this method and the reduction in the duration of inpatient treatment associated with its use, it should still be noted that there is a fairly high incidence of wound suppuration, statistics of which are generally ignored in the literature. According to A. P. Chadayev (2002), the incidence of wound suppuration after applying a primary suture in a clinic specifically treating purulent mastitis is at least 8.6%. Despite the small percentage of suppuration, an open method of wound management with subsequent application of a primary-delayed or secondary suture should still be considered safer for widespread clinical use. This is due to the fact that it is not always clinically possible to adequately assess the volume of tissue damage by the purulent-inflammatory process and, therefore, perform a complete necrectomy. The inevitable formation of secondary necrosis, high contamination of the wound with pathogenic microorganisms increase the risk of relapse of purulent inflammation after the application of the primary suture. The extensive residual cavity formed after radical CHO is difficult to eliminate. The exudate or hematoma accumulated in it leads to frequent suppuration of the wound even under conditions of seemingly adequate drainage. Despite the healing of the mammary gland wound by primary intention, the cosmetic result after surgery when using 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 perform radical CHO. We treat the wound openly using ointments on a water-soluble basis, iodophor solutions or drainage sorbents. In case of SIRS symptoms and extensive damage to the mammary gland, we prescribe antibacterial therapy (oxacillin 1.0 g 4 times a day intramuscularly or cefazolin 2.0 g 3 times intramuscularly). In case of non-lactational purulent mastitis, empirical antibacterial therapy includes cefazolin + metronidazole or lincomycin (clindamycin), or amoxiclav in monotherapy.

During postoperative treatment, the surgeon has the opportunity to control the wound process, directing it in the right direction. Over time, inflammatory changes in the wound area are stably stopped, its microflora contamination decreases below the critical level, the cavity is partially filled with granulations.

At the second stage, after 5-10 days, we perform skin grafting of the mammary gland wound with local tissues. Considering that more than 80% of patients with purulent mastitis are women under 40, we consider the stage of restorative treatment to be extremely important and necessary for obtaining good cosmetic results.

Skin grafting is performed using the J. Zoltan technique. The edges of the skin, walls and bottom of the wound are excised, giving it a wedge-shaped form convenient for suturing, if possible. The wound is drained with a thin through-perforated drainage brought out through counter-openings. The residual cavity is eliminated by applying deep sutures from absorbable thread on an atraumatic needle. An intradermal suture is applied to the skin. The drainage is connected to a pneumatic aspirator. There is no need for constant wound washing with the two-stage treatment tactics; only aspiration of wound discharge is performed. The drainage is usually removed on the 3rd day. In case of lactorea, the drainage can be left in the wound for a longer period. The intradermal suture is removed on the 8-10th day.

Performing skin grafting after the purulent process has subsided allows to reduce the number of complications to 4.0%. At the same time, the degree of deformation of the mammary gland decreases, and the cosmetic result of the intervention increases.

Usually, the purulent-inflammatory process affects one mammary gland. Bilateral lactational purulent mastitis is quite rare, occurring in only 6% of cases.

In some cases, when purulent mastitis results in a small flat wound of the mammary gland, it is sutured tightly, without the use of drainage.

Treatment of severe forms of purulent non-lactational purulent mastitis, occurring with the participation of anaerobic flora, especially in patients with a burdened anamnesis, presents significant difficulties. The development of sepsis against the background of an extensive purulent-necrotic focus leads to high mortality.