Postoperative Nausea and Vomiting with Plastic Surgery: A Practical Advisory to Etiology, Impact, and Treatment.

Ambulatory surgery is common in plastic surgery, where many aesthetic and reconstructive procedures can be performed in hospitals, ambulatory surgery centers, or office-based surgery facilities. Outpatient surgery offers advantages to both the patient and the surgeon by increasing accessibility, flexibility, and convenience; lowering cost; and maintaining high-quality care. To optimize a patient's experience and comfort, postoperative nausea and vomiting (PONV) should be prevented. However, in those patients who develop PONV, it must be appropriately managed and treated. The incidence of PONV is variable. It is often difficult to accurately predict those patients who will develop PONV or how they will manifest symptoms. There are a variety of recommended "cocktails" for PONV prophylaxis and treatments that are potentially effective. The decision regarding the type of treatment given is often more related to provider preference and determination of side-effect profile, rather than targeted to specific patient characteristics, because of the absence of large volumes of reliable data to support specific practices over others. Fortunately, there are several tenets for the successful prevention and treatment of PONV we have extracted from the literature and summarize here. The following is a summary for the practicing plastic surgeon of the current state of the literature regarding PONV cause, risk factors, prophylaxis, and treatment that may serve as a guide for further study and practice management.

Risk of severe and refractory postoperative nausea and vomiting in patients undergoing diep flap breast reconstruction.

BACKGROUND: Postoperative nausea and vomiting (PONV) are commonly feared after general anesthesia and can impact results. The primary aim of our study was to examine incidence and severity of PONV by investigating complete response, or absence of PONV, to prophylaxis used in patients undergoing DIEP flaps. Our secondary aims were definition of the magnitude of risk, state of the art of interventions, clinical sequelae of PONV, and interaction between these variables, specifically for DIEP patients. METHODS: A retrospective chart review occurred for 29 patients undergoing DIEP flap breast reconstruction from September 2007 to February 2008. We assessed known patient and procedure-specific risks for PONV after DIEPs, prophylactic antiemetic regimens, incidence, and severity of PONV, postoperative antiemetic rescues, and effects of risks and treatments on symptoms. RESULTS: Three or more established risks existed in all patients, with up to seven risks per patient. Although 90% of patients received diverse prophylaxis, 76% of patients experienced PONV, and 66% experienced its severe form, emesis. Early PONV (73%) was frequent; symptoms were long lasting (average 20 hours for nausea and emesis); and multiple rescue medications were frequently required (55% for nausea, 58% for emesis). Length of surgery and nonsmoking statistically significantly impacted PONV. CONCLUSION: We identify previously undocumented high risks for PONV in DIEP patients. High frequency, severity, and refractoriness of PONV occur despite standard prophylaxis. Plastic surgeons and anesthesiologists should further investigate methods to optimize PONV prophylaxis and treatment in DIEP flap patients.

Mediastinoscopy and video-assisted thoracoscopic surgery: anesthetic pitfalls and complications.

Endoscopic evaluation of the thoracic cavity was first described in 1910 when Jacobaeus used a cystoscope for pleural examination. Significant advances in thoracoscopic surgery, including the use of high-definition videoscopy and refinements in surgical technique, have created a vast array of increasingly complex procedures that can be performed. The minimally invasive nature of video-assisted thoracoscopic surgery (VATS) makes it ideal for diagnostic and therapeutic procedures in ambulatory and critically ill patients. Mediastinoscopy is often performed immediately preceding VATS to permit sampling of mediastinal lymph nodes. As the indications for thoracoscopic surgery expand, the anesthesiologist must be familiar with common anesthetic and surgical complications, which occur in up to 9% of patients.

Surgical management of anterior chamber epithelial cysts.

PURPOSE: To review management strategies for treatment of anterior chamber epithelial cysts. DESIGN: Retrospective review of consecutive interventional case series. METHODS: Charts of patients treated for epithelial ingrowth over a 10-year period by a single surgeon were reviewed. Cases of anterior chamber epithelial cysts were identified and recorded, including details of ocular history, preoperative and postoperative acuity, intraocular pressure (IOP), and ocular examination, type of surgical intervention, and details of further procedures performed. RESULTS: Seven eyes with epithelial cysts were identified. Patient age ranged from 1.5 to 53 years at presentation. Four patients were children. In four eyes, cysts were secondary to trauma, one case was presumably congenital, one case developed after corneal perforation in an eye with Terrien's marginal degeneration, and one case developed after penetrating keratoplasty (PK). Three eyes were treated with vitrectomy, en bloc resection of the cyst and associated tissue, fluid-air exchange and cryotherapy. The last four eyes were treated with a new conservative strategy of cyst aspiration (three cases) or local excision (one keratin "pearl" cyst), and endolaser photocoagulation of the collapsed cyst wall/base. All epithelial tissue was successfully eradicated by clinical criteria; one case required repeat excision (follow-up, 9 to 78 months, mean 45). Two eyes required later surgery for elevated IOP, two for cataract extraction and one for repeat PK. Final visual acuity ranged from 20/20 to hand motions, depending on associated ocular damage. Best-corrected visual results were obtained in the more conservatively managed eyes. CONCLUSIONS: Anterior chamber epithelial cysts can be managed conservatively in selected cases with good results. This strategy may be particularly useful in children's eyes, where preservation of the lens, iris, and other structures may facilitate amblyopia management.

Surgical approaches to the management of epithelial cysts.

PURPOSE: The purpose of this study was to review management strategies for treatment of epithelial cysts. STUDY DESIGN: Retrospective consecutive interventional case series. METHODS: Charts of patients treated for epithelial ingrowth over a 10-year period by a single surgeon (J.A.H.) were reviewed. Cases of epithelial cysts were identified and the following data were recorded: details of ocular history, preoperative and postoperative visual acuity, intraocular pressure (IOP), ocular examination findings, type of surgical intervention, and details of subsequent procedures performed. RESULTS: Seven eyes with epithelial cysts were identified. Patients ranged in age from 1 1/2 years to 53 years at presentation. Three patients were children. Four cysts were due to trauma, one was presumably congenital, one developed after corneal perforation in an eye with Terrien's marginal degeneration, and one developed after penetrating keratoplasty. Three patients were treated with vitrectomy, en bloc resection of the cyst and associated tissue, fluid-air exchange, and cryotherapy. Four patients were treated with conservative strategy consisting of cyst aspiration (three cases) or local excision (one "keratin pearl" cyst) and endolaser photocoagulation of the collapsed cyst wall or base. In all cases, the epithelial tissue was successfully eradicated; one case required a second excision (follow-up, 9 months to 78 months; mean, 45 months). Two eyes required subsequent surgery for elevated IOP, two for cataract extraction, and one for a second penetrating keratoplasty. Final visual acuity ranged from 20/20 to hand motions, depending on associated ocular damage. Best visual results were obtained in the more conservatively managed eyes. CONCLUSION: Epithelial cysts can be managed conservatively in selected patients with good results. This strategy may be particularly useful in children, in whom preservation of the lens, iris, and other structures may facilitate amblyopia management.