Postoperative Management After Total Pharyngolaryngectomy Using the Free Ileocolon Flap: A 5-Year Surgical Intensive Care Unit Experience.

INTRODUCTION: Management after total pharyngolaryngectomy with free ileocolon flaps can be challenging. Adequate postoperative surgical guidelines are essential to avoid complications. Factors, such as agitation, hypotension, or prolonged mechanical ventilation, might compromise final outcomes. Herein, we describe our experience in the early postoperative care of patients after total pharyngolaryngectomy with immediate reconstruction using the free ileocolon flap. METHODS: This is a retrospective review of all patients who underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. Demographics, etiology of resection, neoadjuvant therapy, surgical time, method of sedation, postoperative use of vasopressors, length of intensive care unit (ICU) stay, time of discontinuation of mechanical ventilation, and complications were recorded and analyzed. RESULTS: Between 2010 and 2015, a total of 34 patients underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. The most common cause of total pharyngolaryngectomy was cancer. Twenty-eight patients had neoadjuvant therapy (radiation). The average surgical time was 11.5 hours (range, 8-14.5 hours), average length of ICU stay was 3 days (range, 2-15 days) with an average time for mechanical ventilation cessation of 3 days (range, 1-20 days). Midazolam and dexmedetomidine were the most common sedatives used during surgery and in the ICU period. Three patients required vasopressors due to hypotension, 2 had unplanned self-extubation from the tracheostomy site, 2 experienced postoperative bleeding, 1 had pneumonia, 4 required unplanned return to the operating room, 2 had partial flap loss, and 1 had complete flap loss. CONCLUSIONS: Overall, a majority of patients recovered well postoperatively with minimal complications and low rate of reoperation. Our research provides a foundation to develop a risk-stratified approach to determine the need for an ICU admission or early transfer to floor care.

Single-Stage Direct-to-Implant Breast Reconstruction: A Comparison Between Subpectoral Versus Prepectoral Implant Placement.

BACKGROUND: Single-stage direct-to-implant (DTI) breast reconstruction can offer several potential benefits. Subpectoral DTI reconstruction can present with animation deformity and pectoralis muscle spasm. To potentially avoid these complications, surgeons have attempted prepectoral placement for DTI; however, the benefits of this approach are mostly unknown. We evaluated the outcomes of DTI between prepectoral and subpectoral placement. METHODS: This was a retrospective review of patients who underwent immediate DTI breast reconstruction (prepectoral vs subpectoral) between 2011 and 2018. Demographics, clinical characteristics, complications, and patient-reported outcomes (BREAST-Q) were compared. RESULTS: Thirty-three patients (55 breasts) underwent prepectoral DTI, and 42 patients (69 breasts) underwent subpectoral DTI. Demographics were similar among groups. The number of breasts with preoperative ptosis lower than grade 2 was not significantly different between groups (29.1% vs 26.1%; P = 0.699). Median follow-up was 20.3 and 21 months in the prepectoral and subpectoral groups, respectively. Average mastectomy weight was 300 g (180-425 g) and 355 g (203-500 g). Average implant size was 410 cc (330-465 cc) and 425 cc (315-534 cc) in the prepectoral and subpectoral groups, respectively. Alloderm was used in all reconstructions. Total numbers of complications were 4 (7.2%) and 8 (11.6%) in the prepectoral and subpectoral groups, respectively (P = 0.227). BREAST-Q demonstrated mean patient satisfaction was high and similar among groups (75 and 73.9, P = 0.211). CONCLUSIONS: Based on these results, we believe prepectoral DTI is safe, reliable, and a promising reconstructive option for selected patients, with equivalent results to other reconstructive options. Our present treatment recommendations are for patients who wish to maintain the same breast size and have minimal or no breast ptosis.

Return of baseline kidney function after bilateral renal artery stent occlusion and treatment delay following fenestrated endografting.

Although renal artery restenosis and thrombotic stent occlusion are not rare occurrences, the literature suggests that prompt diagnosis and treatment are essential to preserve renal function, particularly in the setting of occlusion. We describe the case of a 75-year-old woman who underwent fenestrated endovascular aneurysm repair and experienced acute anuric renal failure requiring dialysis secondary to bilateral renal artery stent occlusion for >48 hours. She was successfully treated with revisional endovascular therapy and made a full renal recovery.

Analysis of clinical outcomes of upper and lower extremity reconstructions in patients with soft-tissue sarcoma.

BACKGROUND AND OBJECTIVES: Primary amputations have been the standard of treatment for extremity soft tissue sarcomas. However, over the last few decades, this mode of treatment has been increasingly replaced by limb-sparing procedures.1 Our goal is to report the clinical outcomes of upper and lower extremity reconstructions in patients with a history of soft-tissue sarcoma. METHODS: A retrospective review of 178 patients with a history of soft-tissue sarcoma who underwent upper or lower extremity reconstructions was conducted. Demographics, tumor characteristics, treatment modalities, type of flap utilized, functional outcomes, and postoperative donor-/recipient-site complications (DSC/RSC) were analyzed. Variables were compared between free and pedicle flaps (FF or PF). RESULTS: PF reconstructions had a higher rate of DSC (P < 0.044), whereas FF reconstructions had a higher rate of RSC (P < 0.03). Upper extremity reconstruction resulted in a mean QuickDASH score of 5.98 (SD 9.37) with no significant difference between PF and FF. Lower extremity reconstruction resulted in a mean score of 71.2 (SD 10.7) for PF and 71.3 (SD 5.1) for FF on the Lower Extremity Function Scale. CONCLUSION: Limb-preserving reconstruction with PF and FF is a reliable and safe option after sarcoma resection. In addition, long-term outcomes are promising and reassure the adequate functionality of the limb.

Increased risk organ transplantation in the pediatric population.

IRD organs are classified by the Public Health Service to be at above-average risk for harboring human immunodeficiency virus, hepatitis C, and hepatitis B. Traditionally underutilized, there exists even greater reluctance for their use in pediatric patients. We performed a retrospective analysis via the United Network for Organ Sharing database of all pediatric renal and hepatic transplants performed from 2004 to 2008 in the United States. Primary outcomes were patient and graft survival. Proportional hazards regression was performed to control for potentially confounding factors. Waitlist time, organ acceptance rates, and infectious transmissions were analyzed. There were 1830 SRD renal, 92 IRD renal, 1695 SRD hepatic, and 59 IRD hepatic transplants. There were no statistically significant differences in allograft or patient survival in either group. Acceptance rates of IRD organs were lower for kidney (1.5% IRD vs 4.82% SRD) and liver (1.99% IRD vs 4.51% SRD). One transmission of a bloodborne pathogen involving a pediatric recipient out of 7797 unique transplants was reported from 2008 to 2015. IRD organs appear to have equivalent outcomes. Increasing their utilization may improve access to transplant while decreasing wait times and circumventing waitlist morbidity and mortality.

Diversity Matters: A 21-Year Review of Trends in Resident Recruitment into Surgical Specialties.

Background: Diversity within the healthcare workforce is essential to improve quality of care, although evaluation of diversity within surgical training remains limited. This study analyzed diversity in recruitment of residents into surgical subspecialties at a large academic medical institution and national trends. Methods: A 21-year cross-sectional study of medical school graduates accepted into all surgical subspecialty training programs was performed. The institutional cohort was divided into two groups (1997-2006, 2007-2017). Subspecialty acceptance rates were determined between 2011 and 2018. Data on candidate demographics including gender, race, ethnicity, citizenship, and origin of medical education at a single institution and nationally were extracted. Results: Two thousand found hundred seventy-two residents were included in this study. From 1997 to 2018, female acceptances increased from 21.1% to 29.7% (p < 0.01), non-White increased from 27.9% to 31.8% (p = 0.01), and international medical graduates decreased from 28.8% to 25.5% (p = 0.02). There was no significant change in accepted Hispanic and Non-US candidates. Female subspecialty rates for subspecialties increased nationally and was comparable to our cohort, except in general surgery. Hispanic subspecialty acceptance rates were less than 10% and Black/African American acceptance rates remained less than 5% across subspecialties nationally and at our institution. Conclusion: Diversity in surgical training has modestly progressed over the last two decades, but the degree of positive change has not been universal and highlights the critical need for improvement and action. Continued institution driven and collaborative strategies are essential to promote diversity in recruitment across all surgical specialties that has implications on our future workforce and surgical leadership.

Gastroepiploic vascularized lymph node transfer for the treatment of extremity lymphedema: comparison between middle and distal inset.

BACKGROUND: Middle and distal insets of gastroepiploic vascularized lymph node transfer (GE-VLNT) for extremity lymphedema have been described. However, there has been no prior comparison of surgical or patient-reported outcomes between these techniques. We analyzed the outcomes between both insets in patients with extremity lymphedema. METHODS: Retrospective review of patients with extremity-lymphedema who underwent GE-VLNT. Two groups were analyzed: middle and distal recipient inset. We analyzed 6-month surgical and patient-reported outcomes using the Lymphedema Life Impact Scale-v2 (LLISv2) and scar satisfaction utilizing the Patient Scar Assessment Questionnaire (PSAQ). RESULTS: Between 2017 and 2019, 26 patients with stage II unilateral extremity lymphedema underwent laparoscopically-harvested GE-VLNT (13 distal and 13 middle inset). There were no differences in patient demographics between groups. Mean hospital stay for patients with upper extremity lymphedema was 1.3 vs. 4.0 days (P<0.05), and for lower extremity lymphedema was 1.0 vs. 4.5 days (P<0.05), middle vs. distal inset, respectively. Mean return to daily activities for patients with upper extremity lymphedema was 13.4 vs. 33.4 days (P<0.05), and for lower extremity lymphedema was 16.0 vs. 29.5 days (P<0.05), middle vs. distal inset, respectively. Both middle and distal inset showed significant mean excess volume reduction at 6 months postoperatively for both upper and lower extremity lymphedema (upper extremity: middle inset 23.3%, distal inset: 22.0%; lower extremity: middle inset 23.3% and distal inset 13.3%). LLISv2 scores showed improved functional outcomes postoperatively in both upper and lower extremity lymphedema with both insets. Scar satisfaction with appearance and symptoms was higher with middle inset (P<0.05). CONCLUSIONS: GE-VLNT is an effective surgical treatment for extremity lymphedema. The middle placement showed shorter hospital stay, early return to work and higher patient satisfaction.

Cost Analysis and Supply Utilization of Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy (LC) is one of the highest volume surgeries performed annually. We hypothesized that there is a statistically significant intradepartmental cost variance with supply utilization variability amongst surgeons of different subspecialty. This study sought to describe laparoscopic cholecystectomy cost of care among three subspecialties of surgeons. This retrospective observational cohort study captured 372 laparoscopic cholecystectomy cases performed between June 2015 and June 2016 by 12 surgeons divided into three subspecialties: 2 in bariatric surgery (BS), 5 in acute care surgery (ACS), and 5 in general surgery (GS). The study utilized a third-party software, Surgical Profitability Compass Procedure Cost Manager and Crimson System (SPCMCS) (The Advisory Board Company, Washington, DC), to stratify case volume, supply cost, case duration, case severity level, and patient length of stay intradepartmentally. Statistical methods included the Kruskal-Wallis test. Average composite supply cost per case was $569 and median supply cost per case was $554. The case volume was 133 (BS), 109 (ACS), and 130 (GS). The median intradepartmental total supply cost was $674.5 (BS), $534 (ACS), and $564 (GS) (P<0.005). ACS and GS presented with a higher standard deviation of cost, $98 (ACS) and $110 (GS) versus $26 (BS). The median case duration was 70 min (BS), 107 min (ACS), and 78 min (GS) (P<0.02). The average patient length of stay was 1.15 (BS), 3.10 (ACS), and 1.17 (GS) (P<0.005). Overall, there was a statistically significant difference in median supply cost (highest in BS; lowest in ACS and GS). However, the higher supply costs may be attenuated by decreased operative time and patient length of stay. Strategies to reduce total supply cost per case include mandating exchange of expensive items, standardization of supply sets, increased price transparency, and education to surgeons.

Analysis of patient-detected breast cancer recurrence.

BACKGROUND: After primary surgical resection, breast cancer survivors regularly undergo surveillance using multiple modalities to detect recurrences. OBJECTIVE: The goal of this study was to determine how breast cancer recurrences were detected in our sample population of breast cancer survivors. We hypothesize that the majority of recurrences are patient-detected. METHODS: This was a retrospective observational study evaluating patients with a detected breast cancer recurrence between 2010 and 2015. Patients were analyzed by initial detection modality (patient versus clinician versus imaging). Other variables of interest included insurance status, ambulation capability, living situation, age at diagnosis and recurrence, and time to recurrence. Statistical methods included chi-square tests, log-rank tests, and analysis of variance. RESULTS: 115 patients were identified with a recurrence (mean age 61 years). 88 (77%) recurrences were patient-detected, 14 (12%) were detected by imaging, and 13 (11%) were clinician-detected (chi-square goodness of fit test p < 0.001). Median time to recurrence was 4 years in the patient-detection group compared to 3 for the clinician group and 2 for imaging detection (log-rank test p = 0.01). CONCLUSION: While the majority of recurrences were patient-detected, these were detected later and at a more advanced clinical stage. This could represent an opportunity to enhance outcomes by empowering patient detection strategies.