Time to completion of nipple reconstruction: what factors are involved?

BACKGROUND: Nipple reconstruction is often used as a marker for completion of the breast reconstructive process. The purpose of this study was to determine the average time to nipple reconstruction and the factors that influence this process. METHODS: All patients who underwent postmastectomy breast reconstruction at Emory University between 2005 and 2011 were reviewed. Only those who had completed nipple reconstruction were included. Variables recorded were body mass index, age, smoking history, surgeon, presence of preoperative or postoperative chemotherapy or radiation therapy, type of reconstruction, timing of reconstruction, unilateral or bilateral reconstruction, and complication history. Time to completion of nipple reconstruction was calculated and comparisons were made. RESULTS: A total of 451 patients completed nipple reconstruction (128 implant reconstructions, 120 latissimus plus implant reconstructions, 23 latissimus only reconstructions, and 180 transverse rectus abdominus myocutaneous flap [TRAM] or deep inferior epigastric perforator flap [DIEP] reconstructions). Average time to nipple reconstruction was 12.25 months. Patients who underwent TRAM or DIEP flaps completed reconstruction on average earlier than implant-based reconstruction and latissimus-only reconstruction (8.67 vs 11.2 and 11.3 months, respectively, P = 0.0016). Patients who underwent postoperative chemotherapy or radiation therapy were delayed compared to those that did not (11.3 vs 9.33 and 13.87 vs 9.87 months, P = 0.0315 and P = 0.0052). Timing of completion was also dependent on attending surgeon (9.8 and 11.43 months for the 2 senior surgeons, P = 0.0135) and presence of complications (10.3 compared to 9.77 months for patients without complications, P = 0.0334). Body mass index, smoking history, preoperative chemotherapy or radiation therapy, timing of reconstruction, and unilateral versus bilateral reconstruction did not affect time to nipple reconstruction. CONCLUSIONS: Type of reconstruction, surgeon, presence of complications, and need for postoperative chemotherapy or radiation therapy all affect timing to completion of breast reconstruction. Patients should be counseled as to these factors at the initial consultation to set appropriate expectations.

Intrapyloric botulinum injection increases postoperative esophagectomy complications.

BACKGROUND: Intrapyloric botulinum toxin injection has emerged as a possible alternative to standard pyloric drainage procedures. Possible advantages include decreased operative time and less postoperative dumping and bile reflux symptoms. However, data are lacking to show its effectiveness versus standard drainage procedures. The purpose of this review is to compare the results in a prospective cohort of patients who received pyloric botulinum injection versus patients who received pyloromyotomy or pyloroplasty with esophagectomy. METHODS: We performed a retrospective review of a prospective database of all patients who underwent an open esophageal resection at a single institution from 2005 through 2010. Three hundred twenty-two patients were divided into 3 groups for analysis: botulinum injection (n = 78), pyloromyotomy (n = 45), and pyloroplasty (n = 199). We compared these groups with respect to duration of the procedure, presence of delayed gastric emptying on postoperative swallow studies, requirement of anastomotic dilation, requirement of pyloric dilation, use of postoperative promotility agents, and patient experience of postoperative symptoms of reflux or dumping, or both. RESULTS: Patients receiving botulinum injections experienced similar delayed gastric emptying on postoperative radiologic evaluation as did patients undergoing pyloromyotomy and pyloroplasty (16% versus 5% and 13%, respectively; p = 0.14). Mean operative time was significantly shorter for the patients receiving botulinum as expected (239 minutes versus 312 minutes and 373 minutes, respectively; p < 0.001). However, more patients receiving botulinum and pyloric dilation (22% versus 4% and 2%, respectively; p < 0.001) experienced postoperative reflux symptoms (32% versus 12% and 13%, respectively; p = 0.001) and used postoperative promotility agents (22% versus 5% and 15%, respectively; p = 0.04). There was no statistical difference between the groups regarding postoperative dumping. CONCLUSIONS: Use of intrapyloric botulinum injection significantly decreased operative time. However, the patients receiving botulinum experienced more postoperative reflux symptoms, had increased use of promotility agents as well as a requirement for postoperative endoscopic interventions, and postoperative dumping was not reduced by the reversible procedure. Intrapyloric botulinum injection should not be used as an alternative to standard drainage procedures. Pyloromyotomy appears to be the drainage procedure of choice to accompany an esophagectomy.