Identifying Factors of Operative Efficiency in Head and Neck Free Flap Reconstruction.

Importance: Head and neck oncological resection and reconstruction is a complex process that requires multidisciplinary collaboration and prolonged operative time. Numerous factors are associated with operative time, including a surgeon's experience, team familiarity, and the use of new technologies. It is paramount to evaluate the contribution of these factors and modalities on operative time to facilitate broad adoption of the most effective modalities and reduce complications associated with prolonged operative time. Objective: To examine the association of head and neck cancer resection and reconstruction interventions with operative time. Design, Setting, and Participants: This large cohort study included all patients who underwent head and neck oncologic resection and free flap-based reconstruction in Calgary (Alberta, Canada) between January 1, 2007, and March 31, 2020. Data were analyzed between November 2021 and May2022. Interventions: The interventions that were implemented in the program were classified into team-based strategies and the introduction of new technology. Team-based strategies included introducing a standardized operative team, treatment centralization in a single institution, and introducing a microsurgery fellowship program. New technologies included use of venous coupler anastomosis and virtual surgical planning. Main Outcomes and Measures: The primary outcome was mean operative time difference before and after the implementation of each modality. Secondary outcomes included returns to the operating room within 30 days, reasons for reoperation, returns to the emergency department or readmissions to hospital within 30 days, and 2-year and 5-year disease-specific survival. Multivariate regression analyses were performed to examine the association of each modality with operative time. Results: A total of 578 patients (179 women [30.9%]; mean [SD] age, 60.8 [12.9] years) undergoing 590 procedures met inclusion criteria. During the study period, operative time progressively decreased and reached a 32% reduction during the final years of the study. A significant reduction was observed in mean operative time following the introduction of each intervention. However, a multivariate analysis revealed that team-based strategies, including the use of a standardized nursing team, treatment centralization, and a fellowship program, were significantly associated with a reduction in operative time. Conclusions: The results of this cohort study suggest that among patients with head and neck cancer, use of team-based strategies was associated with significant decreases in operative time without an increase in complications.

Exploring breast surgeons' reasons for women not undergoing immediate breast reconstruction.

INTRODUCTION: Factors influencing breast reconstruction rates in Canada are complex and multi-factorial, ranging from patient-related to systemic considerations. For plastic surgeons, rates of immediate breast reconstruction (IBR) hinge on referral patterns from general surgeons performing breast cancer surgery and informed discussions with patients about their goals and risk tolerance. We seek to understand the reasons Alberta patients are not receiving IBR as reported by general surgeons. METHODS: The Synoptec™ database is a synoptic operative report designed by Cancer Surgery Alberta™ and utilized by 95% of Alberta breast cancer surgeons. Within this report are mandatory questions regarding if a patient is receiving IBR and, if not, why. A retrospective review of this database was performed for all patients undergoing surgical treatment of breast cancer over two years. All statistical comparisons were made using chi-squared test for categorical variables with a p-value of 0.05 considered significant. RESULTS: Of 6253 patients undergoing breast cancer surgery, 2649 underwent mastectomy and 615 mastectomy patients received IBR. The most commonly reported reasons patients did not undergo IBR were patient preference (55%), high likelihood of postoperative radiation therapy (20%), and high risk due to patient co-morbidities (12%). Resource limitations (2%) and a lack of an IBR discussion (3%) was rarely cited as reasons for no IBR. CONCLUSIONS: There are many reconstructive options following mastectomy in breast cancer survivors. This study provides a unique look into general surgeon reported reasons patients are not receiving IBR and demonstrates the need for further probing into the thought-process behind these reported reasons from both a surgeon and patient perspective.

Adoption of Enhanced Recovery after Surgery Protocols in Breast Reconstruction in Alberta Is High before a Formal Program Implementation.

BACKGROUND: Enhanced recovery after surgery (ERAS) techniques have consistently demonstrated improved patient outcomes across multiple surgical specialties. We have lead international consensus guidelines on ERAS protocols for breast reconstruction and recently implemented these guidelines in Alberta. This study looks at adoption rates of ERAS pathways for breast reconstruction within Alberta, whereas also addressing barriers to ERAS implementation. METHODS: A retrospective analysis of online operative reports in the Synoptec database consisting of patients undergoing alloplastic or autogenous breast reconstruction in Alberta was conducted. Primary outcomes of interest included whether ERAS protocols were utilized and what the reported barriers to ERAS utilization were. RESULTS: Of the 372 patients undergoing breast reconstruction surgery, 215 (57%) patients were placed on an ERAS protocol. Autogenous reconstruction patients were more likely than alloplastic reconstruction patients to be placed on ERAS protocols (72% versus 53%, P = 0.002). A lack of resources was the most commonly cited reason for not adopting ERAS protocols for both autogenous and alloplastic reconstruction groups (53% and 53%). Surgeons in Southern Alberta were more likely than surgeons in Northern Alberta to utilize ERAS protocols for their alloplastic (73% versus 8%, P < 0.001) and autogenous (99% versus 4%, P < 0.001) reconstructions. CONCLUSIONS: Adoption of ERAS protocols in Alberta was strong (57% adherence) before a formal program implementation. We are encouraged that the recent official launch of ERAS protocols in breast reconstruction within the province will further enhance the uptake and care of this unique surgical population.

Enhanced Recovery After Surgery (ERAS) Protocol Enables Safe Same-Day Discharge After Alloplastic Breast Reconstruction.

BACKGROUND: To compare enhanced recovery after surgery (ERAS) with traditional recovery after surgery (TRAS) for patients undergoing alloplastic breast reconstruction. METHODS: A retrospective chart review of 2 patient groups (ERAS and TRAS) undergoing alloplastic breast reconstruction was performed. Data were collected from 2012 to 2013 (TRAS) and from 2013 to 2016 (ERAS). The ERAS protocol included day surgery, multimodal analgesia, and preoperative anti-emetic. The TRAS pathway involved overnight admission, narcotic-based analgesia, and no preoperative anti-emetic. Demographics, operative variables, and complications were compared between groups. RESULTS: Seventy-eight ERAS patients and 78 TRAS patients were included. Length of stay was shorter for ERAS patients (0.38 nights ERAS and 1.45 nights TRAS; P < .001). The ERAS patients underwent significantly more bilateral surgery (80.8% ERAS and 55.1% TRAS; P < .001), immediate reconstruction (98.6% ERAS and 89.3% TRAS; P = .004), and had more implants versus expanders placed (66% [93/141] ERAS and 24.8% TRAS; P < .001). There were no differences in the number of post-operative emergency department visits (8% ERAS and 14% TRAS; P = .2) and readmissions (8% ERAS and 3.8% TRAS; P = .3) between the groups. There was no difference in the rate of hematoma (0.7% ERAS and 0% TRAS; P = .35), infection requiring explantation (1.4% ERAS and 0.8% TRAS; P = .65), infection requiring outpatient IV antibiotics (1.4% ERAS and 2.5% TRAS; P = .53), and infection requiring IV antibiotics and readmission (2.1% ERAS and 1.7% TRAS; P = .78) between the groups. There were no differences in the number of minor complications (22% ERAS and 23% TRAS; P = .82). CONCLUSION: The ERAS protocol for alloplastic breast reconstruction is safe, without increased readmission or complication rates compared to TRAS, and significantly decreased length of stay.

HISTORIQUE: Comparer la récupération rapide après la chirurgie (RRAC) à la récupération habituelle après la chirurgie (RHAC) chez les patientes qui subissent une récupération mammaire alloplastique. MÉTHODOLOGIE: Les chercheurs ont procédé à l'analyse rétrospective des dossiers de deux groupes de patientes (RRAC et RHAC) qui subissaient une reconstruction mammaire alloplastique. Ils ont recueilli les données de 2012 et 2013 (RHAC) et de 2013 à 2016 (RRAC). Le protocole RRAC incluait une chirurgie d'un jour, une analgésie multimodale et un anti-émétique préopératoire. La voie RHAC incluait l'admission d'une nuit, une analgésie narcotique et l'absence d'anti-émétique préopératoire. Les chercheurs ont comparé les données démographiques, les variables opératoires et les complications entre les groupes. RÉSULTATS: Au total, 78 patientes RRAC et 78 patientes RHAC ont participé à l'étude. Les patientes RRAC étaient hospitalisées moins longtemps (0,38 nuit RRAC, 1,45 nuit RHAC, p<0,001). Les patientes RRAC ont subi beaucoup plus de chirurgies bilatérales (80,8 % RRAC, 55,1 % RHAC, p<0,001) et de reconstructions immédiates (98,6 % RRAC, 89,3 % RHAC, p=0,004) et se sont fait installer plus d'implants que d'expanseurs (66 % RRAC [93 sur 141], 24,8 % RHAC, p<0,001). Les groupes ne présentaient pas de différence quant au nombre de rendez-vous postopératoires à l'urgence (8 % RRAC, 14 % RHAC, p=0,2) et de réhospitalisations (8 % RRAC, 3,8 % RHAC, p=0,3). Ils ne présentaient pas de différences quant au taux d'hématomes (0,7 % RRAC, 0 % RHAC, p=0,35) ni d'infection exigeant l'explantation (1,4 % RRAC, 0,8 % RHAC, p=0,65), la prise d'antibiotiques IV ambulatoires (1,4 % RRAC, 2,5 % RHAC, p=0,53) ou la prise d'antibiotiques IV et une réhospitalisation (2,1 % RRAC, 1,7 % RHAC, p=0,78). Le nombre de complications mineures ne différait pas davantage (22 % RRAC, 23 % RHAC, p=0,82). CONCLUSION: Le protocole RRAC de reconstruction mammaire alloplastique est sécuritaire, n'accroît pas le taux de réhospitalisations ou de complications par rapport à la RHAC et réduit le séjour hospitalier de manière significative.