Trends of medicare reimbursement for breast cancer and reconstructive surgery.

This study evaluated trends in Medicare reimbursement for commonly performed breast oncologic and reconstructive procedures. Average national relative value units (RVUs) for physician-based work, facilities, and malpractice were collected along with the corresponding conversion factors for each year. From 2010 to 2021, there was an overall average decrease of 15% in Medicare reimbursement for both breast oncology (-11%) and reconstructive procedures (-16%). Based on these findings, breast and reconstructive surgeons should advocate for reimbursement that better reflects the costs of their practice.

Patients prescribed antithrombotic medication in elective implant-based breast reconstruction are high risk for major thrombotic complications.

INTRODUCTION: Implant-based reconstruction (IBR) is the most frequently performed breast reconstruction procedure in the USA. As the US population ages, an increasing number of these patients suffer from comorbidities requiring the use of chronic antithrombotic therapy. Outcomes following IBR in patients prescribed these medications are not well understood. MATERIALS/PATIENTS AND METHODS: An all-payor administrative claims database (52 million patients) was queried for patients undergoing IBR from 2010 through 2018. Patients who were prescribed therapeutic antithrombotic therapy, and those who were not, were matched in a one-to-one fashion for comorbidities independently associated with bleeding and thrombo-ischemic events following first-stage IBR. Cox proportional hazards models investigated the 90-day risk of bleeding and major thrombo-ischemic events following IBR. RESULTS: Of the 36,379 patients found to have undergone IBR, 2,024 patients were perfectly matched for age and high-risk comorbidities. Patients prescribed antithrombotic drugs had increased 90-day risk for all thrombo-ischemic complications (HR: 5.62, 95% CI: 3.53-8.95, p < 0.0001), as well as a significantly increased risk for 90-day DVT, 90-day PE, 90-day myocardial infarction, and 90-day stroke. Patients specifically prescribed antiplatelet drugs, direct oral anticoagulants (DOAC), and warfarin had a significantly increased risk for transfusion. CONCLUSION: Patients prescribed antithrombotic therapy had a significantly increased risk for life-threatening thrombotic events and transfusion following elective IBR. This suggests a role for further monitoring and a potential role for multi- and interdisciplinary interventions to help mitigate this risk. These interventions can be the subject of future prospective studies.

Improved patient outcomes in paraesophageal hernia repair using a laparoscopic approach: a study of the national surgical quality improvement program data.

A consensus on the optimal surgical approach for repair of a paraesophageal hernia has not been reached. The aim of this study was to examine the outcomes of open and laparoscopic paraesophageal hernia repairs (PHR), both with and without mesh. A review of the National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2011 was conducted. Patients who underwent an open or laparoscopic PHR were included. The primary outcome was 30-day mortality. Secondary outcomes included infections, respiratory and cardiac complications, intraoperative or perioperative transfusions, sepsis, and septic shock. Statistical analyses using odds ratios were performed comparing the open and laparoscopic approaches. A total of 4470 patients were identified using NSQIP; 2834 patients had a laparoscopic repair and the remaining 1636 patients underwent an open PHR. Compared with the laparoscopic approach, the open repair group had significantly higher 30-day mortality (odds ratio, 4.75; 95% confidence interval, 2.67 to 8.47; P < 0.0001). The laparoscopic approach had a statistically significant decrease in infections, respiratory and cardiac events/complications, transfusion requirements, episodes of sepsis, and septic shock (P < 0.05). Our data suggest increased perioperative morbidity associated with an open PHR compared with laparoscopic. There was no statistically significant difference in any of the primary or secondary outcomes in patients repaired with mesh compared with those without. The overall use of mesh in paraesophageal hernia repairs has increased. The NSQIP data show significantly increased 30-day mortality in open repair compared with laparoscopic as well as a significantly higher perioperative complication rate.

Chemoprevention by cyclooxygenase-2 inhibition reduces immature myeloid suppressor cell expansion.

Selective inhibitors of cyclooxygenase-2 (COX-2) enzyme activity have shown chemopreventive activity in carcinogen-induced and transgenic rodent tumor models and clinically for colon cancer. However, the mechanism(s) by which COX-2 inhibitors reduce carcinogenesis remains controversial. We report herein that administration of the selective COX-2 inhibitor, celecoxib, significantly reduces the number of Gr1(+)CD11b(+) immature myeloid suppressor cells (IMSCs) during chemoprevention of 1,2-dimethylhydrazine diHCl-(1,2-DMH-) induction of large intestinal tumors in Swiss mice. Celecoxib administration also increased splenic lymphatic number and tumor infiltration by lymphocytes. The 1,2-DMH induction of large intestinal tumors was associated with a four-fold increase in IMSCs, and a decrease in splenic T cell number and function. Concordant with the changes in the IMSC frequency, messenger ribonucleic acid (mRNA) levels of inducible nitric oxide synthase (NOS-2) and arginase (Arg) were increased in the spleen of the tumor-bearing mice and normalized by celecoxib administration. In addition to delaying tumor induction, reducing tumor number, and increasing lymphocyte infiltration of tumors, celecoxib therapy reversed CD4(+) T cell loss, decreased IMSC numbers and increased mRNA levels of NOS-2 and Arg in the spleen. In summary, our results suggest that celecoxib chemoprevention of autochthonous intestinal tumors can regulate IMSCs and CD4(+) T cell numbers.