Postoperative Complications Associated with the Choice of Reconstruction in Head and Neck Cancer: An Outcome Analysis of 4,712 Patients from the ACS-NSQIP Database.

BACKGROUND: Microsurgical free flaps have largely supplanted pedicled flaps as the gold standard for head and neck cancer reconstruction. However, incidence of postoperative complications after accounting for patient comorbidities based on choice of reconstruction has not been well-defined in the literature in recent years. METHODS: Patients undergoing head and neck reconstruction were identified in the 2011-2016 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database and stratified into groups by free flap, myocutaneous pedicled flap, and other reconstruction. Demographics were analyzed and covariates balanced using overlap propensity score-based weighting. Logistic regression was used for binary outcomes and Gamma generalized linear model was used for length of stay. RESULTS: A total of 4,712 patients met inclusion criteria out of which 1,297 patients (28%) underwent free flap, 208 patients (4%) pedicled flap, and 3,207 patients (68%) had other, or no reconstruction performed. After adjusting for patient and disease-specific factors, pedicled flap reconstruction was associated with a higher risk of deep vein thrombosis (odds ratio [OR] = 2.64, confidence interval [CI] 1.02-6.85, p = 0.045), sepsis (OR = 2.95, CI 1.52-5.71, p = 0.001), and infection (OR = 2.03, CI 1.39-2.96, p <0.001) compared with free flap reconstruction. Free flaps had the longest mean operative time compared with the other two groups (unadjusted 578 vs. 440 vs. 326, p <0.001). Pedicled flaps had a lower incidence of bleeding requiring transfusion (adjusted OR = 0.65, CI 0.50-0.85, p = 0.002), and lower incidence of prolonged mechanical ventilation (adjusted OR = 0.33, CI 0.12-0.92, p = 0.034) compared with free flaps. There was no difference in rates of reoperation, hospital readmission, or hospital length-of-stay between pedicled and free flaps. CONCLUSION: Myocutaneous pedicled flaps are associated with higher overall short-term postoperative complications compared with free flaps in head and neck reconstruction, which demonstrate a more favorable morbidity profile without significantly impacting hospital readmission, reoperation, or length-of-stay.

Occupational Radiation Exposure Among General Surgery Residents: Should We Be Concerned?

BACKGROUND: Low-dose ionizing radiation exposure is associated with development of solid organ tumors as well as increased risk of cataract formation in a linear-dose response. While occupational radiation exposure has been studied across subspecialties with regular fluoroscopy exposure such as interventional radiology and urology, the contribution of increasing endovascular case volume to occupational radiation exposure among general surgery residents remains largely unreported. In this study, we sought to determine typical occupational radiation exposure among a pool of general surgery residents as part of a formal radiation safety curriculum. METHODS: A radiation safety program was introduced to a group of 28 general surgery residents who rotate on a vascular surgery service with a high endovascular volume in a hybrid room setting. All residents received training in proper use of a radiation dosimeter and minimizing exposure during fluoroscopy times in the operating room. Data was collected from radiation film dosimetry badges distributed to general surgery residents on a bimonthly basis throughout the year, and radiation exposure in mRem was compared between residents rotating on vascular and nonvascular surgical services during 4-week rotations. RESULTS: A total of 14 months of data were collected. Resident compliance was 84% with regular use and return of dosimeters at the end of each bimonthly cycle. The radiation exposure among residents rotating on vascular surgery was significantly higher compared to those on nonvascular rotations (mean = 71 mRem vs 3.13 mRem, p = 0.02). Exposure among senior residents was not statistically different than that of attending vascular surgeons (mean = 212 mRem vs 164 mRem, p = 0.20). All exposures were significantly lower than institutional ALARA dose limits for radiation exposure (5000 mRem/year). CONCLUSION: General surgery residents are routinely exposed to measurable occupational radiation levels, especially while participating in endovascular procedures during their training. However, data from our study suggests that these levels are below ALARA dose limits and senior surgical residents are not at greater risk than vascular surgery attending surgeons while on their vascular rotation. The results of this study will be used to help guide resident education on radiation safety and identify institution-specific practices which can minimize exposure and improve radiation safety adherence.

Regional Pain Blocks and Perioperative Pain Control in Patients Undergoing Breast Implant Removal With Capsulectomy.

Background: Demand for breast implant removal is on the rise, with more than 36,000 explants performed in 2020, an increase of 7.5% from previous years. Postoperative (PO) analgesia is an important consideration in this patient group due to scar tissue surrounding the implant and the potential for extensive dissection during capsulectomy. Objectives: The authors sought to compare perioperative pain control between three different types of ultrasound (US)-guided regional anesthetic techniques in patients undergoing implant removal with capsulectomy. Methods: The authors reviewed all patients who received an US-guided block and underwent breast implant removal with capsulectomy at their outpatient surgical center over a 2-year period. They compared intraoperative (IO), PO opioid requirement, and patient-reported pain on the first postoperative day (POD1) between 3 different block techniques using chi-square analysis. A P-value of <.05 was considered statistically significant. Results: A total of 352 patients were included. Twenty-six patients (7.4%) underwent a serratus plane (SP) block, 13 (3.7%) underwent an erector spinae combined with pectointercostal fascial plane (ES + PIFP) block, and 313 (88.9%) underwent an erector spinae combined with pectoral nerve (ES + PECS1) block. ES + PECS1 was associated with less IO and PO opioid use compared with SP and ES + PIFP (1.9% vs 19.2% vs 61.5%, P < .001 for IO, 26.8% vs 34.6% vs 38.5% PO, P < .001). The ES + PECS1 block was associated with mild pain on POD1 compared with the other 2 regional block techniques (P = .001). Conclusions: Regional pain blocks, and specifically the ES block, offer effective pain control for patients undergoing breast implant removal with capsulectomy, demonstrating high patient satisfaction in the PO period with low opioid requirements.

Outcomes of Implant Removal and Capsulectomy for Breast Implant Illness in 248 Patients.

BACKGROUND: Breast implant illness (BII) is a term popularized by social media to describe systemic symptoms that patients ascribe to their breast implants. Though the concept of implants as an underlying cause for a systemic illness remains controversial, few studies have delineated the implant characteristics, capsular histology, and outcomes of patients who undergo explantation for BII. METHODS: We retrospectively reviewed the demographics, presenting symptoms, outcomes, capsular histology, and culture results of all women who presented to the senior author with symptoms attributed to BII and underwent breast implant removal with capsulectomy from August 2016 to February 2020. Chi-square and logistic regression analyses were performed to evaluate association between implant type, composition, and findings of inflammation on capsule pathology. RESULTS: Among 248 patients, 111 (23%) capsules demonstrated inflammatory changes on permanent pathology. Capsular inflammation was independently associated with silicone versus saline (right odds ratio [OR] = 2.18 [1.16-4.11], P = 0.016, left OR = 2.35 [1.08-5.12], P = 0.03) and textured versus smooth implants (right OR = 2.18 [1.16-4.11], P = 0.016, left OR = 2.25 [1.17-4.31], P = 0.01). Silicone material was present in the capsules of 12 patients (4.8%). Fourteen patients had positive cultures. There was one pneumothorax (0.4%), three hematomas requiring evacuation (1%), and two DVTs (0.8%). Of 228 patients, 206 (90.4%) reported high satisfaction with the outcome of the procedure. CONCLUSIONS: In a large cohort of BII patients, we found that capsular inflammation is significantly associated with silicone and textured implants. Implant removal with capsulectomy can be safely performed in patients with BII with a low complication rate and high patient satisfaction.

Breast Reconstruction in Inflammatory Breast Cancer: An Analysis of Predictors, Trends, and Survival from the National Cancer Database.

INTRODUCTION: Survival for women diagnosed with inflammatory breast cancer (IBC) has improved with advances in multimodal therapy. This study was performed to evaluate trends, predictors, and survival for reconstruction in IBC patients in the United States. METHODS: Women who underwent mastectomy with or without reconstruction for IBC between 2004 and 2016 were included from the National Cancer Database. Predictors for undergoing reconstruction and association with overall survival were determined. RESULTS: Of 12,544 patients with IBC who underwent mastectomy, 1307 underwent reconstruction. Predictors of reconstruction included younger age, private insurance, higher income, performance of contralateral prophylactic mastectomy, and location within a metropolitan area (P < 0.001). The proportion of women having reconstruction for IBC increased from 7.3% to 12.3% from 2004 to 2016. Median unadjusted overall survival was higher in the reconstructive group l [93.7 months, 95% confidence interval (CI) 75.2-117.5] than the nonreconstructive group (68.1 months, 95% CI 65.5-71.7, hazard ratio = 0.79 95% CI 0.72-0.88, P < 0.001). With adjustment for covariates, differences in overall mortality were not significant, with hazard ratio of 0.95 (95% CI 0.85-1.06, P = 0.37). CONCLUSIONS: Reconstruction rates for IBC are increasing. Women with IBC who undergo reconstruction tend to be younger and are not at the increased risk of all-cause mortality compared to those not having reconstruction. The National Cancer Database does not differentiate immediate from delayed reconstruction. However, the outcomes of immediate reconstruction in carefully selected patients with IBC should be further studied to evaluate its safety. This could impact current guidelines, which are based largely on an expert opinion.