Precise Analgesic Instructions Improve Narcotic Usage: A Randomized Trial.

BACKGROUND: Given the ongoing battle with opioid abuse and overuse in the United States, new strategies are consistently being implemented to reduce opioid utilization and overprescribing. OBJECTIVES: The purpose of this study was to determine if a more regulated explicit pain management instruction plan could reduce the number of opioids taken. METHODS: Blinded randomized prospective study comparing a total of 110 (Group A = 55, Group B = 55) women who underwent elective outpatient bilateral breast reduction surgery by 2 different plastic surgeons. Patients were randomly divided into either Group A (control) that received general pain management instructions or Group B (experimental) that received explicit pain management instructions from the surgeons and nurses. Participants were asked to record the number of times they treated their pain with each separate modality. They were also asked to record their average daily pain scale for the days that they were treating their pain. RESULTS: Patients in Group B took on average 1.5 oxycodone (5 mg) and patients in Group A took on average 5.7 oxycodone (5 mg) (P < 0.01). Thirty-four patients in Group B took no oxycodone. Patients in Group B also had statistically significant lower subjective pain scores. CONCLUSIONS: Based on these results, it appears that standardizing how patients are instructed to treat their pain postoperatively may reduce the number of narcotics needed, thus reducing the number of narcotics prescribed without compromising pain control.

Prepectoral Conversion of Subpectoral Implants for Animation Deformity after Breast Reconstruction: Technique and Experience.

Implant-based breast reconstruction in postmastectomy patients is commonly performed in a submuscular plane. Following reconstruction, animation deformity can be a displeasing aesthetic result for patients. In addition, patients may experience more postoperative pain with a submuscular reconstruction. Prepectoral conversion of submuscular implant position is an option for addressing these concerns. We describe a detailed technique and review our results. METHODS: A retrospective review was conducted of all prepectoral conversions performed by the senior author (DSW) from 2017 to 2019 after IRB approval. All patients presented with animation deformity and another symptom such as asymmetry, pain, and/or capsular contracture. Patients underwent prepectoral conversion with smooth silicone gel implants. Demographic data, outcomes, and patient satisfaction were reviewed. RESULTS: Prepectoral conversion was performed in 33 consecutive patients (57 breasts) with animation deformity. Twelve patients had capsular contracture, seven complained of pain, and five had ruptured implants. Postoperative complications included three infections requiring implant removal in two breasts, one implant exposure and one hematoma requiring implant replacement, five seromas requiring aspiration, and one capsular contracture. Seven patients had contour abnormalities addressed with secondary autologous fat grafting. Ultimately, all patients had elimination of animation deformity and were satisfied with the results of the conversion. CONCLUSIONS: Unsatisfactory results of subpectoral implant reconstruction such as animation deformity and chronic pain have led the reconstructive surgeon to consider various techniques to address these issues. The conversion to a prepectoral plane will effectively eliminate animation deformity, resolve pain, and yield satisfactory results in these patients.

Role of Prophylactic Sartorius Flaps for Preventing Deep Space Infection in Lower Extremity Revascularization.

Groin infections in vascular surgery are common and compromise the goal of limb preservation. Strategies to prevent deep space infection (DSI) include incision orientation and muscle flaps. Literature evaluating prophylactic flaps preventing DSI is scarce. We aimed to compare prophylactic sartorius flaps to layered closure in preventing readmission for DSI, along with the effect of incision orientation. This was a retrospective study of vascular surgery patients at a single institution with femoral artery exposure from 2017-2021. Patients with active groin infections were excluded. Prophylactic sartorius flaps were compared to those with layered closure regarding 30-day hospital readmission for DSI. Oblique versus vertical incisions was compared regarding the primary outcome. Fifty-three patients received sartorius flaps, and 122 received layered closure. Seventy patients had oblique incisions, and 105 patients had vertical incisions. Sartorius flaps had a higher rate of previous groin surgery compared to layered closure (45.3% vs. 24.7%, p<0.01). Vertical incisions had a higher rate of previous groin surgery (38.1% vs. 20.0%, p<0.02), while oblique incisions had a higher rate of obesity (24.3% vs. 8.6%, p<0.01). There was a lower rate of DSI in sartorius flaps compared to layered closure (1.9% vs. 6.6%, p=2.80), although not statistically significant due to lack of power. There was no difference in DSI in the oblique versus vertical incisions (4.3% and 5.7%, p=0.760). Patients with prophylactic sartorius flaps experienced fewer DSI, although further evaluation with increased sample size is required for adequate study power. We believe sartorius flaps are a simple solution to prevent groin complications.

Primary Peritoneal Carcinosarcoma: A Case Report.

Introduction: Carcinosarcoma, also known as malignant mixed Mullerian tumor (MMMT) is a malignant biphasic neoplasm consisting of carcinomatous and malignant non-epithelial components of mesenchymal origin. MMMTs typically arise from the female genital tract in patients over 40 years old. Primary extragenital MMMTs are extremely rare with published literature totaling 40 reported cases. The primary peritoneal carcinosarcoma is an aggressive tumor as patients with this tumor have an average survival of 7.6 months. Surgical debulking is the mainstay of treatment for these tumors and systemic chemotherapy is advised in all cases. Case: A 48-year-old Amish female presented with 5 day history of bloating and abdominal pain superimposed on a 1 year history of worsening fatigue and intermittent bloody bowel movements. She was found to have a pelvic mass on physical exam. Computed tomography scan of the abdomen and pelvis that demonstrated stricturing of the sigmoid colon, and a large multi-cystic mass in the midline pelvis measuring 12.5 × 9.9 × 11.7 cm. Colonoscopy showed stenosis due to external compression without intraluminal lesion. CEA and CA 125 levels were elevated and CA 19-9 was normal. Exploratory laparotomy was performed with en-bloc resection of a 15 cm mass originating from the sigmoid colon mesentery with several other small tumor deposits throughout the mesentery. Pathology diagnosed primary peritoneal carcinosarcoma Mullerian-type with three positive lymph nodes. Conclusion: Malignant mixed Mullerian tumor (carcinosarcoma) caries a universally grim prognosis. Herein, we report a unique case of primary peritoneal carcinosarcoma and discuss the work-up and surgical management of this rare tumor.

A case report of a retained interventricular septal bullet after gunshot wound.

Cardiac gunshot injuries herald a universally grim prognosis. We present an exceedingly unique case of a patient surviving multiple gunshot wounds with two bullet fragments lodged in the interventricular septum. A 25-year-old male sustained four gunshot wound injuries to the upper body. Two cardiac interventricular septal bullet fragments were identified during his recovery. Management included serial echocardiographic surveillance and a two-month regimen of empiric colchicine for prophylaxis against post-traumatic pericarditis. Pursuing non-operative management especially in asymptomatic or stable patients should be evaluated against surgical extraction and possible sequelae of complications. The consideration of scheduled colchicine for pericarditis prophylaxis is warranted as well as interval echocardiogram. Retained myocardial bullets are exceedingly rare clinical events with scant literature available to guide clinical decisions. Management requires intricate decision-making and close consideration of risk benefit analysis weighing surgical extraction against non-operative management.