Safety of upper extremity surgery after prior treatment for ipsilateral breast cancer: Results of an American Society for Surgery of the Hand membership survey and literature review

Lymphedema, infection, and healing delay are among feared complications in patients undergoing upper extremity surgery after prior mastectomy and axillary dissection with or without radiation therapy. Most of these cancer patients are advised to avoid any procedure on their ipsilateral upper extremity including blood pressure monitoring, intravenous punctures, and surgery. As a result, many of these patients hesitate to undergo necessary upper extremity surgery such as arthritis surgery and even carpal tunnel release. Many hand and upper extremity surgeons believe that these precautions are unnecessarily stringent and believe that indicated upper extremity surgeries could be performed safely in these patients. We surveyed 1,200 members of The American Society for Surgery of the Hand and the 606 returned questionnaires were analyzed. More than 95% of the hand surgeons surveyed do not hesitate to perform surgery on an upper extremity in a patient after ipsilateral lymphadenectomy and/or irradiation, decreasing to 85% if there is pre-existing chronic lymphedema; 94% use a tourniquet in a routine fashion (74% use a tourniquet in the presence of existing lymphedema); 46% use a Bier block when clinically indicated (only 21% would use a Bier block in a patient with lymphedema); and 36% are comfortable using an axillary block (25% in the case of lymphedema). Thus, most of the polled surgeons would prefer to perform surgery on these patients under a general anesthetic, but still would use an extremity tourniquet for a bloodless surgical field in their routine manner. The rate of reported complications in these patients was 23% in patients with pre-existing chronic lymphedema and only 3% in patients with no lymphedema. After surgery, 46.2% of the surgeons do not undertake any additional precautions than in their routine practice with all upper extremity surgery patients. However, 53.8% would change their routine practice for such patients and these changes range from placing the surgical tourniquet on the forearm instead of the upper arm, use of perioperative prophylactic antibiotics in all patients irrespective of the type of surgery, use of postoperative compression garments, and specific postoperative hand therapy aimed at the prevention of postoperative edema.