Efficacy of the enhanced recovery after surgery protocol on reducing surgical disparities related to overweight/obesity in deep inferior epigastric perforator flap breast reconstruction.

BACKGROUND: When choosing a method of deep inferior epigastric perforator (DIEP) flap for breast reconstruction, concerns regarding the potentially detrimental effects of obesity on postoperative recovery remain. Enhanced recovery after surgery (ERAS) is known to facilitate rapid postoperative recovery. This study aimed to examine the effect of the ERAS protocol on the disparity between normal/underweight and overweight/obese patients after DIEP flap breast reconstruction. METHODS: A retrospective review of consecutive patients who underwent DIEP flap breast reconstruction between January 2015 and November 2022 was conducted. The patients were categorized into two groups: pre-ERAS and post-ERAS. In each group, associations between overweight/obese patients (BMI ≥25 kg/m2 ) and postoperative course were evaluated. RESULTS: In total, 217 patients in the pre-ERAS group (including 71 overweight/obese) and 165 in the post-ERAS group (including 58 overweight/obese) were analyzed. The post-ERAS group had shorter length of stay (LOS) (8.0 versus 7.0 days, p-value <.001) and lower postoperative pain scores (5.0 versus 3.0 at postoperative day (POD) 1, p-value <.001) than the pre-ERAS group. The complication profiles did not differ according to ERAS adoption. In the pre-ERAS group, overweight/obese patients showed a significantly longer LOS (8.0 versus 9.0 days, p-value = .017) and a higher postoperative pain score (3.0 versus 4.0 at POD 2, p-value = .018) than normal/underweight patients; however, these differences disappeared in the post-ERAS group, showing similar LOS, pain scores, and analgesic consumption. CONCLUSIONS: Implementation of the ERAS protocol in DIEP free-flap breast reconstruction may reduce overweight/obesity-related disparities in postoperative recovery.

Predictors, management and prognosis of initial hyperemia of free flap.

In free flap operation, temporary hyperemia of the transferred flaps can often be encountered in the early postoperative period, appearing reddish and rapid capillary refilling time, which mimics venous congestion. This study aimed to investigate the factors associated with the development of hyperemia and evaluate clinical course. Consecutive patients who underwent free flap-based reconstruction between December 2019 and October 2021 were reviewed. Independent risk factors associated with its development were assessed. Flap showing initial hyperemic features were assessed using flap blood glucose measurement (BGM). If it showed over 60 mg/dL, they were closely observed without management. Their clinical outcomes were evaluated. In total, 204 cases were analyzed, of which 35 (17.2%) showed initial hyperemia. Multivariable analyses showed that using thoracodorsal artery perforator flaps and muscle containing flaps (musculocutaneous/muscle-chimeric flaps) and conducting end-to-end arterial anastomosis (vs. end-to-side) were independent predictors. All cases with initial hyperemia showed over 60 mg/dL in BGM. The phenomenon resolved spontaneously within 6.9 h averagely. Overall perfusion-related complications developed in 10 (4.9%) cases, which rate did not differ between the two groups. Several factors might be associated with the development of initial hyperemia after free flap surgery. With proper assessment, this condition can be successfully managed without unnecessary intervention.

Surgical Treatment of Enlarged Cervical Leiomyoma with Concomitant Uterine Prolapse: A Case Report.

This case report details the surgical treatment of a rare enlarged cervical leiomyoma with uterine prolapse in a 48-year-old woman. She presented to Konyang University Hospital with a palpable vaginal mass, lower abdominal pain, and urinary incontinence. Despite being nulliparous, she had severe chronic constipation due to schizophrenia medication and lived in a health care facility separated from her family. Pelvic examination revealed stage 3 uterine prolapse with a large necrotic cervical leiomyoma. A robot-assisted vaginal hysterectomy followed by sacrocolpopexy was performed using the Da Vinci Xi Surgical System. Histopathology confirmed cervical leiomyoma with squamous metaplasia. At a three-month follow-up, there were no complications, pelvic anatomy was restored, and urinary incontinence improved. Although the patient had a systemic infection due to the necrotic cervical leiomyoma, raising concerns about the increased risk of infection associated with mesh use, she was high-risk for pelvic organ prolapse (POP) recurrence due to her medical history and living situation. Therefore, she underwent concurrent surgeries with pre- and postoperative antibiotic treatment, and recovered without complications. Given that the risk of developing POP increases after a hysterectomy, in high-risk patients, as demonstrated in this case, the concurrent surgical correction of POP may be an effective strategy.

The early postoperative effects of rinsing the breast pocket with tranexamic acid in prepectoral prosthetic breast reconstruction.

BACKGROUND: The efficacy of tranexamic acid (TXA) has been reported in breast surgery; however, its application and duration have varied across studies. This study aimed to assess the early postoperative outcomes of rinsing the breast pocket with TXA during prepectoral prosthetic breast reconstruction using an acellular dermal matrix (ADM). METHODS: A retrospective chart review was conducted in consecutive patients who underwent immediate prosthetic prepectoral reconstruction between August 2021 and December 2022. For cases performed during the earlier part of the study period (up to April 2022), TXA was not administered (non-TXA group), whereas those performed after April 2022 received topical TXA application during surgery (TXA group). Postoperative outcomes including hematoma, seroma, drainage volume, and drain maintenance duration were compared between the two groups using propensity score matching (PSM). RESULTS: A total of 674 breasts were analyzed; 280 in the TXA group and 394 were in the non-TXA group. There were 251 breasts in each group after PSM, and their characteristics were similar. The incidence of hematoma in the first 24 hours and total drain output were significantly lower in the TXA group than the non-TXA group. In cases of direct-to-implant cases, the TXA group showed a significantly lower seroma rate. CONCLUSIONS: Rinsing the breast pocket with TXA can potentially reduce the occurrence of hematoma and decrease drain output in prepectoral ADM-assisted prosthetic breast reconstruction. Moreover, this approach may be beneficial in lowering the incidence of seroma in direct-to-implant reconstruction.