Assessing the Quality of Reporting on Quality Improvement Initiatives in Breast Reconstruction: A Systematic Review.

BACKGROUND: There has been a recent increase in the number and complexity of quality improvement (QI) studies in breast reconstruction. To assist with the development of thorough QI reporting practices, with the goal of improving the transferability of these initiatives, the authors conducted a systematic review of studies describing the implementation of QI initiatives in breast reconstruction. The authors used the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guideline to appraise the quality of reporting of these initiatives. METHODS: English language articles published in Embase, MEDLINE, CINAHL, and the Cochrane databases were searched. Quantitative studies evaluating the implementation of QI initiatives in breast reconstruction were included. The primary endpoint of interest in this review was the distribution of studies according to SQUIRE 2.0 criteria scores in proportions. Abstracts and full-text screening, and data extraction were completed independently and in duplicate by the review team. RESULTS: The authors screened 1107 studies, of which 53 full texts were assessed and 35 met inclusion criteria. In our assessment, only three studies (9%) met all 18 SQUIRE 2.0 criteria. SQUIRE 2.0 criteria that were met most frequently were abstract, problem description, rationale, and analysis. The lowest SQUIRE 2.0 scores appeared in the interpretation criteria. CONCLUSIONS: Significant opportunity exists to improve QI reporting in breast reconstruction, especially in the realm of costs, strategic tradeoffs, ethical considerations, project sustainability, and potential for spread to other contexts. Improvements in these areas will help to further advance the transferability of QI initiatives in breast reconstruction.

A comparison of patient-reported outcomes between Alloderm and Dermacell in immediate alloplastic breast reconstruction: A randomized control trial.

BACKGROUND: Alloderm and Dermacell are the two leading human acellular dermal matrices (ADM) in immediate breast reconstruction (IBR). Despite differences in sterility, consistency, thickness and cost, there are no comparative trials to date to compare patient-reported outcome measures (PROM) between the two products. The purpose of this study was to determine if there was a difference in patient-reported outcomes (as measured by the BREAST-Q) between patients reconstructed with Alloderm and Dermacell. METHODS: A single center, open-label, randomized control trial of patients undergoing IBR with an implant for breast cancer or breast cancer prophylaxis was performed. Patients were randomized to either Alloderm or Dermacell. Baseline demographic data were compared, and linear mixed models were used to identify associations with BREAST-Q over time. RESULTS: Between June 2016 and October 2018, 62 patients were randomized into two groups, 31(50%) Alloderm and 31(50%) Dermacell. Of these, 23(74%) patients in the Alloderm group and 27(87%) patients of the Dermacell group filled out BREAST-Q questionnaires. Baseline BREAST-Q scores with respect to satisfaction with breasts, psychosocial well-being, sexual well-being, and physical well-being were similar between groups (p>0.05). At 3 months postoperatively, the Alloderm group had a statistically significant improvement with respect to satisfaction with breasts (67 vs 53, p = 0.03), satisfaction with overall results (85 vs 61, p = 0.003), satisfaction with the surgeon (89 vs 67, p = 0.01), and satisfaction with information provided (74 vs 59, p = 0.02). At 12 months postoperatively, there were no statistically significant differences in PROM between groups (p>0.05). CONCLUSION: We report the first randomized controlled trial to date comparing patient-reported outcomes of the two most commonly used ADMs in IBR in Canada. Although a short-term analysis favors the use of Alloderm, there does not appear to be any difference in outcomes between the two products in the longer term.

The Impact of Delaying Breast Reconstruction on Patient Expectations and Health-Related Quality of Life: An Analysis Using the BREAST-Q.

PURPOSE: An understanding of patient expectations predicts better health outcomes following breast reconstruction. No study to date has examined how patient expectations for breast reconstruction and preoperative health-related quality of life vary with time since breast cancer diagnosis. METHODS: Women consulting for breast reconstruction to a single surgeon's practice over a 13-month period were enrolled in this cross-sectional study. Patients were asked to prospectively complete the BREAST-Q expectations and preoperative reconstruction modules. A retrospective chart review was then performed on eligible patients, and patient demographics, cancer-related factors, and comorbidities were collected. BREAST-Q scores were transformed using the equivalent Rasch method. Multivariate linear regression models were constructed to assess the association between BREAST-Q scores and time since cancer diagnosis. RESULTS: Sixty-five patients met inclusion criteria for analysis and are characterized by a mean age of 53 ± 11 (34-79) years and a mean body mass index of 28 ± 6 (19-49). Most patients were treated by mastectomy (58%) or lumpectomy (23%). At the time of retrospective chart review, 29 (43%) patients had undergone reconstruction, most of which were delayed (59%). The mean latency from cancer diagnosis to reconstruction was 685 ± 867 days (range: 28-3322 days). Latency from cancer diagnosis to reconstruction was associated with a greater expectation of pain (ß = 0.5; standard error [SE] = 0.005; 95% confidence interval [CI]: 0.003-0.027; P < .05), and a slower expectation for recovery (ß = -0.5; SE = 0.004; 95% CI: -0.021 to -0.001; P < .05) after breast reconstruction. Latency from cancer diagnosis to reconstruction was associated with an increase in preoperative psychosocial well-being (ß = 0.578; SE 0.009; 95% CI: 0.002-0.046; P < .05). CONCLUSION: Delaying breast reconstruction may negatively impact patient expectations of postoperative pain and recovery. Educational interventions aimed at understanding and managing patient expectations in the preoperative period may improve health-related quality of life and patient-related outcomes following initial breast cancer surgery.

OBJECTIF: La compréhension des attentes des patientes est prédictive de meilleurs résultats cliniques après une reconstruction mammaire. Jusqu'à présent, aucune étude n'a porté sur la manière dont les attentes des patientes à l'égard de la reconstruction mammaire et de la qualité de vie liée à la santé avant l'opération varient dans le temps à compter du diagnostic de cancer du sein. MÉTHODOLOGIE: Les femmes qui ont consulté le cabinet d'un seul chirurgien en vue d'une reconstruction mammaire sur une période de 13 mois ont participé à la présente étude transversale. Les patientes ont été invitées à remplir de manière prospective les modules BREAST-Q sur les attentes préopératoires et la reconstruction. Les chercheurs ont ensuite procédé à un examen rétrospectif des dossiers des patients admissibles, puis ont colligé des données sur la démographie des patients, les facteurs liés au cancer et les morbidités associées. Ils ont transformé les scores BREAST-Q à l'aide du modèle de Rasch équivalent. Ils ont construit des modèles de régression linéaire multivariés pour évaluer l'association entre les scores BREAST-Q et la période écoulée depuis le diagnostic de cancer. RÉSULTATS: Soixante-cinq patientes respectaient les critères d'inclusion. Elles se caractérisaient par un âge moyen de 53 ± 11 ans (34 à 79 ans) et un indice de masse corporelle moyen de 28 ± 6 (19 à 49). La plupart des patientes ont été traitées par mastectomie (58 %) ou lumpectomie (23 %). Au moment de l'analyse rétrospective des dossiers, 29 (43 %) avaient subi une reconstruction, dont la plupart avaient été retardées (59 %). La latence moyenne entre le diagnostic de cancer et la reconstruction était de 685 ± 867 jours (plage de 28 à 3 322 jours). La latence entre le diagnostic de cancer et la reconstruction s'associait à une plus grande anticipation de la douleur (ß=0,5; ÉT=0,005; intervalle de confiance [IC] à 95 % de 0,003 à 0,027; P<0,05) et à des anticipations plus basses envers la convalescence (ß = -0,5; ÉT = 0,004; IC à 95 % de -0,021 à -0,001; P<0,05) après la reconstruction mammaire. La latence entre le diagnostic de cancer et la reconstruction était liée à une augmentation du bien-être psychosocial préopératoire (ß = 0,578; ÉT = 0,009; IC à 95 % de 0,002 à 0,046; P<0,05). CONCLUSION: Le report de la reconstruction mammaire peut avoir un effet négatif sur l'anticipation des patientes à l'égard de la douleur préopératoire et de la convalescence. Des interventions pédagogiques pour comprendre et gérer les attentes des patientes pendant la période préopératoire peuvent améliorer la qualité de vie liée à la santé et les résultats cliniques des patientes après la chirurgie initiale d'un cancer du sein.

Ambulatory latissimus dorsi flap breast reconstruction: A prospective cohort study of an enhanced recovery after surgery (ERAS) protocol.

PURPOSE: Enhanced recovery after surgery (ERAS) protocols improve quality of recovery and decrease length of stay for patients undergoing both alloplastic and autologous breast reconstruction. Their use in latissimus dorsi (LD) flap reconstruction has not been well established. The purpose of this study was to compare postoperative outcomes, length of stay, and total costs in a prospectively enrolled group of patients who underwent LD flap breast reconstruction using an ERAS protocol to those of a retrospective cohort of patients who were treated with a traditional recovery after surgery (TRAS) protocol. METHODS: In a prospective cohort study conducted from 2016 to 2019, an ERAS protocol was implemented for patients undergoing LD flap breast reconstruction. The primary outcome was 24-h discharge, and secondary outcomes were readmission rate, complications, and quality of recovery. Outcomes of patients who underwent LD flap reconstruction with the ERAS protocol were compared with those of a retrospective cohort of patients who underwent LD flap reconstruction with TRAS protocols. RESULTS: Twenty patients enrolled in the ERAS group were compared with 58 patients in the TRAS group. Postoperatively, 100% of ERAS patients were discharged within 24 h (60% on the same day) as compared to 21% (9% on the same day) in the TRAS group (p<0.0001). Minor and major complication rates were similar (30% ERAS vs. 33% TRAS and 20% ERAS vs. 10% TRAS, respectively, p > 0.05). There was significant reduction in length of stay and total cost between the two groups (6.4 h vs. 58.5 h (p = 0.003) and $5,666.80 vs. $8890.25 (p = 0.0003), respectively). CONCLUSIONS: Breast reconstruction with the LD flap can be performed safely and effectively in the ambulatory setting. The implementation of an ERAS protocol was successful in discharging all patients home within 24 h, and the expedited discharge was associated with an acceptable complication rate, reduced length of stay, and excellent quality of recovery. Conversion from TRAS to ERAS protocols was associated with $3,223.45 cost savings per patient.

Breast reconstruction following conservative mastectomies: predictors of complications and outcomes.

Breast reconstruction can be performed using a variety of techniques, most commonly categorized into an alloplastic approach or an autologous tissue method. Both strategies have certain risk factors that influence reconstructive outcomes and complication rates. In alloplastic breast reconstruction, surgical outcomes and complication rates are negatively impacted by radiation, smoking, increased body mass index (BMI), hypertension, and prior breast conserving therapy. Surgical factors such as the type of implant material, undergoing immediate breast reconstruction, and the use of fat grafting can improve patient satisfaction and aesthetic outcomes. In autologous breast reconstruction, radiation, increased BMI, certain previous abdominal surgery, smoking, and delayed reconstruction are associated with higher complication rates. Though a pedicled transverse rectus abdominis myocutaneous (TRAM) flap is the most common type of flap used for autologous breast reconstruction, pedicled TRAMs are more likely to be associated with fat necrosis than a free TRAM or deep inferior epigastric perforator (DIEP) flap. Fat grafting can also be used to improve aesthetic outcomes in autologous reconstruction. This article focuses on factors, both patient and surgical, that are predictors of complications and outcomes in breast reconstruction.

How acidic is the lidocaine we are injecting, and how much bicarbonate should we add?

BACKGROUND: The infiltration of local anesthetics can be painful, which is likely due, in part, to their acidity. In spite of a Cochrane study that recommended neutralizing lidocaine with bicarbonate to decrease the pain of injection, not many surgeons have adopted the practice, and there are many 'recipes' for how much bicarbonate one should add. OBJECTIVE: To determine the acidity of lidocaine and the correct ratio of bicarbonate that should be added to neutralize lidocaine to achieve body pH. METHODS: Fifty samples each of commonly used anesthetics (lidocaine 1% and 2%, with and without epinephrine 1:100,000) were obtained and tested for pH. Data were also analyzed according to whether the vials had been previously opened. Ten additional samples of lidocaine 1% with 1:100,000 epinephrine were titrated against sodium bicarbonate 8.4% and tested for pH and the presence of precipitate. RESULTS: A solution of 1% lidocaine with 1:100,000 epinephrine had a mean (± SD) pH of 4.24±0.42, and 2% lidocaine with 1:100,000 epinephrine had a mean pH of 3.93±0.43. Plain 1% lidocaine had a pH of 6.09±0.16, and plain 2% lidocaine had a pH of 6.00±0.27. Epinephrine-containing solutions were more acidic when they had been previously opened. One per cent lidocaine with epinephrine required 8.4% sodium bicarbonate at a ratio of 1.1 mL:10 mL to 1.8 mL:10 mL to achieve the target tissue pH of 7.38 to 7.62. CONCLUSION: Lidocaine with epinephrine was approximately 1000 times more acidic than subcutaneous tissue. The addition of bicarbonate to the local anesthetic solution is simple to perform and is inexpensive. The proper volume ratio of 8.4% sodium bicarbonate to 1% lidocaine with 1:100,000 epinephrine is approximately 1 mL:10 mL. Surgeons should be more aware of the simplicity and value of buffering with bicarbonate to decrease the pain of injection.

HISTORIQUE: L'infiltration d'anesthésiques locaux peut être douloureuse, ce qui est probablement causé, en partie, par leur acidité. Même si une étude antérieure a recommandé de neutraliser la lidocaïne avec du bicarbonate pour atténuer la douleur de l'injection, peu de chirurgiens ont adopté cette pratique, et il existe de nombreuses « recettes ¼ de la quantité de bicarbonate à ajouter. OBJECTIF: Déterminer l'acidité de la lidocaïne et le bon ratio de bicarbonate à y ajouter pour la neutraliser et parvenir au pH corporel. MÉTHODOLOGIE: Les chercheurs ont obtenu 50 échantillons de chacun des anesthésiques couramment utilisés (lidocaïne 1% et 2%, avec et sans dilution d'adrénaline 1:100 000) et en ont vérifié le pH. Ils ont également analysé les données pour vérifier si les fioles avaient été ouvertes au préalable. Ils ont titré dix échantillons supplémentaires de lidocaïne1% contenant de l'adrénaline 1:100 000 à l'aide de bicarbonate de sodium 8,4 %, puis ont vérifié le pH et la présence de précipité. RÉSULTATS: Une dilution 1:100 000 de lidocaïne 1 % contenant de l'adrénaline avait un pH moyen (±ÉT) de 4,24±0,42, et la lidocaïne 2 % contenant de l'adrénaline, un pH de 3,93±0,43. La lidocaïne 1 % seule avait un pH de 6,09±0,16, et la lidocaïne 2 % seule, un pH de 6,00±0,27. Les solutions contenant de l'adrénaline étaient plus acides lorsqu'elles avaient été ouvertes au préalable. De la lidocaïne 1 % contenant de l'adrénaline devait contenir 8,4 % de bicarbonate de sodium à une dilution de 1,1:10 à 1,8:10 pour parvenir au pH tissulaire ciblé de 7,38 à 7,62. CONCLUSION: La lidocaïne contenant de l'adrénaline était environ 1 000 fois plus acide que les tissus sous-cutanés. Il est simple et peu coûteux d'ajouter du bicarbonate à une solution anesthésique locale. La bonne proportion entre le volume de bicarbonate de sodium 8,4 % et la lidocaïne 1 % accompagnée d'adrénaline 1:100 000 est d'environ 1:10. Les chirurgiens devraient connaître la simplicité et la valeur d'utiliser une solution tampon de bicarbonate pour atténuer la douleur de l'injection.

Determination of correct implant size in radial head arthroplasty to avoid overlengthening: surgical technique.

BACKGROUND: Insertion of a radial head implant that results in radial overlengthening has been associated with altered elbow kinematics, increased radiocapitellar joint forces, capitellar erosions, early-onset arthritis, and loss of elbow flexion. The purpose of this study was to identify clinical and radiographic features that may be used to diagnose overlengthening of the radius intraoperatively and on postoperative radiographs. METHODS: Radial head implants of varying thicknesses were inserted into seven cadaver specimens, which were then assessed clinically and radiographically. Eight stages were examined: the intact specimen (stage 1); repair of the lateral collateral ligament (stage 2); radial head resection with repair of the lateral collateral ligament (stage 3); insertion of an implant of the correct thickness (stage 4); and insertion of an implant that resulted in radial overlengthening of 2 mm (stage 5), 4 mm (stage 6), 6 mm (stage 7), or 8 mm (stage 8). The specimens were tested with and without muscle loading to simulate resting muscle tone and surgical paralysis, respectively. At each stage, radiographs were made to measure the ulnohumeral joint space and the lateral ulnohumeral joint was visually assessed. RESULTS: We identified no difference, with regard to medial ulnohumeral joint incongruity as seen radiographically, among stages 1 through 6 during the tests with muscle loading. A significant difference in medial ulnohumeral joint incongruity was found in stages 7 (p = 0.003) and 8 (p < 0.001). The clinical (visually assessed) lateral ulnohumeral joint space gap was negligible in stages 1 through 4 but increased significantly at all stages involving overlengthening (gross gap, 0.9 mm with 2 mm of erlengthening [p = 0.005], 2.3 mm with 4 mm of overlengthening [p < 0.001], 3.4 mm with 6 mm [p < 0.001], and 4.7 mm with 8 mm [p < 0.001]). CONCLUSIONS: Incongruity of the medial ulnohumeral joint becomes apparent radiographically only after overlengthening of the radius by ≥6 mm. Intraoperative visualization of a gap in the lateral ulnohumeral joint is a reliable indicator of overlengthening following the insertion of a radial head prosthesis.

Determination of correct implant size in radial head arthroplasty to avoid overlengthening.

BACKGROUND: Insertion of a radial head implant that results in radial overlengthening has been associated with altered elbow kinematics, increased radiocapitellar joint forces, capitellar erosions, early-onset arthritis, and loss of elbow flexion. The purpose of this study was to identify clinical and radiographic features that may be used to diagnose overlengthening of the radius intraoperatively and on postoperative radiographs. METHODS: Radial head implants of varying thicknesses were inserted into seven cadaver specimens, which were then assessed clinically and radiographically. Eight stages were examined: the intact specimen (stage 1); repair of the lateral collateral ligament (stage 2); radial head resection with repair of the lateral collateral ligament (stage 3); insertion of an implant of the correct thickness (stage 4); and insertion of an implant that resulted in radial overlengthening of 2 mm (stage 5), 4 mm (stage 6), 6 mm (stage 7), or 8 mm (stage 8). The specimens were tested with and without muscle loading to simulate resting muscle tone and surgical paralysis, respectively. At each stage, radiographs were made to measure the ulnohumeral joint space and the lateral ulnohumeral joint was visually assessed. RESULTS: We identified no difference, with regard to medial ulnohumeral joint incongruity as seen radiographically, among stages 1 through 6 during the tests with muscle loading. A significant difference in medial ulnohumeral joint incongruity was found in stages 7 (p = 0.003) and 8 (p < 0.001). The clinical (visually assessed) lateral ulnohumeral joint space gap was negligible in stages 1 through 4 but increased significantly at all stages involving overlengthening (gross gap, 0.9 mm with 2 mm of overlengthening [p = 0.005], 2.3 mm with 4 mm of overlengthening [p < 0.001], 3.4 mm with 6 mm [p < 0.001], and 4.7 mm with 8 mm [p < 0.001]). CONCLUSIONS: Incongruity of the medial ulnohumeral joint becomes apparent radiographically only after overlengthening of the radius by >or=6 mm. Intraoperative visualization of a gap in the lateral ulnohumeral joint is a reliable indicator of overlengthening following the insertion of a radial head prosthesis.