Adverse events associated with mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers

Management of High-Risk Squamous Cell Carcinoma of the Skin

OPINION STATEMENT

Non-melanoma skin cancer (NMSC) is the most common malignancy in the USA, with cutaneous squamous cell carcinomas (cSCCs) constituting approximately 20 % of all NMSC. While cSCCs typically behave in an indolent fashion and can be cured with local destructive or surgical methods, a small subset metastasizes and induces significant morbidity and mortality. Identifying and aggressively treating these "high-risk" cSCCs (HRcSCCs) is thus paramount. Recent improvements in staging cSCCs appear to offer better risk stratification than earlier staging criteria. Radiologic imaging and sentinel lymph node biopsy may be beneficial in certain cases of HRcSCC, although more studies are needed before these techniques should be uniformly incorporated into management. Surgery with complete margin control, such as that offered by the Mohs micrographic technique, represents the first-line treatment for these tumors. Radiation therapy is likely most beneficial in the adjuvant setting. Chemotherapy is typically best reserved for patients with metastatic or locally advance disease that is not controllable with surgical and/or radiation therapies. Newer targeted treatments, such as EGFR inhibitors and immunotherapies may offer greater efficacy in these settings, although further evaluation is needed.

Is it safe to use local anesthesia with adrenaline in hand surgery? WALANT technique

In the past it was taught that local anesthetic should not be used with adrenaline for procedures in the extremities. This dogma is transmitted from generation to generation. Its truth has not been questioned, nor the source of the doubt. In many situations the benefit of use was not understood, because it was often thought that it was not necessary to prolong the anesthetic effect, since the procedures were mostly of short duration. After the disclosure of studies of Canadian surgeons, came to understand that the benefits went beyond the time of anesthesia. The WALANT technique allows a surgical field without bleeding, possibility of information exchange with the patient during the procedure, reduction of waste material, reduction of costs, and improvement of safety. Thus, after passing through the initial phase of the doubts in the use of this technique, the authors verified its benefits and the patients’ satisfaction in being able to immediately return home after the procedures.

Addressing Practice Gaps in Cutaneous Surgery: Advances in Diagnosis and Treatment

Importance

Cutaneous surgery is performed by otolaryngologists, plastic surgeons, oculoplastic surgeons, dermatologic surgeons, and some primary care physicians. Practice gaps exist among cutaneous surgeons, as do differences in how different physicians approach preoperative, intraoperative, and postoperative decision-making.

Objective

To present the newest and best evidence to close common practice gaps in cutaneous surgery.

Evidence Review

We performed a detailed search of peer-reviewed publications that were identified through a search of PubMed/MEDLINE (January 1, 2000, through June 30, 2016) using the literature search terms "cutaneous surgery," "Mohs micrographic surgery," "plastic surgery," in combination with "safety," "cost," "anesthesia," "anti-coagulation," "bleeding," "pain," "analgesia," "anxiety," or "infection," among others. Bibliographies from these references, as well as meta-analyses, were also reviewed.

Findings

A total of 73 peer-reviewed studies, including randomized clinical trials, were selected to support the conclusions of the article. Levels of evidence were analyzed for selected studies using recommendations from the American Association of Plastic Surgeons based on guidelines from the Oxford Centre for Evidence-Based Medicine. Large cutaneous surgical resections can be done effectively and safely, taking steps to assure patient comfort under local anesthesia. Medically necessary anticoagulant and antiplatelet medication should be continued during cutaneous surgery. In preparation for surgery, patient anxiety and pain must be addressed. Music and anxiolytics limit anxiety, prevent cardiovascular compromise, and improve patient satisfaction. Cutaneous surgeons and support staff should carefully consider the dose and injection angle of local anesthetic. Postoperative opioids and topical antibiotics might cause harm to patients and should be avoided. Acetaminophen and ibuprofen provide adequate pain control with fewer adverse effects than opioid medications.

Conclusions and Relevance

Clinicians performing cutaneous surgery should understand the importance of patient safety and comfort, as guided by recent evidence.

The characteristics of Mohs surgery performed by dermatologists who learned the procedure during residency training or through postgraduate courses and observational preceptorships

Little is known about the practice characteristics of Mohs surgery performed by physicians who learned the procedure during their dermatology residency training or through postresidency courses and observational preceptorships. All published reports have investigated Mohs surgeons trained in postresidency fellowships. This report presents the results of a multicenter prospective cohort study evaluating 1834 consecutive Mohs surgery cases performed during the same 6-month period by 9 Mohs surgeons who learned the technique in residency or in postresidency courses and observational preceptorships. One major complication was reported, a hematoma requiring outpatient drainage in an emergency room. There were 54 (2.9%) short-term complications, including 20 (1.1%) infections, 17 (0.9%) wound dehiscences, 9 (0.5%) cases of skin flap necrosis, and 8 (0.4%) hematomas or postoperative bleeding episodes. These complication rates and the data evaluating tumor type, anatomic location, primary vs. recurrent tumor status, tumor size, postoperative wound size, number of Mohs surgery stages, and repair type compare favorably to previously published reports.

Identifying and defining complications of dermatologic surgery to be tracked in the American College of Mohs Surgery (ACMS) Registry

BACKGROUND

In recent years, increasing emphasis has been placed on value-based health care delivery. Dermatology must develop performance measures to judge the quality of services provided. The implementation of a national complication registry is one such method of tracking surgical outcomes and monitoring the safety of the specialty.

OBJECTIVE

The purpose of this study was to define critical outcome measures to be included in the complications registry of the American College of Mohs Surgery (ACMS).

METHODS

A Delphi process was used to reach consensus on the complications to be recorded.

RESULTS

Four major and one minor complications were selected: death, bleeding requiring additional intervention, functional loss attributable to surgery, hospitalization for an operative complication, and surgical site infection.

LIMITATIONS

This article addresses only one aspect of registry development: identifying and defining surgical complications.

CONCLUSION

The ACMS Registry aims to gather data to monitor the safety and value of dermatologic surgery. Determining and defining the outcomes to be included in the registry is an important foundation toward this endeavor.

Role of antiseptics in the prevention of surgical site infections

BACKGROUND

Antiseptics are chemical agents used to reduce the microbial population on the surface of the skin and are used in nearly every surgical procedure today. Despite this, there are currently no definitive guidelines on surgical preoperative antisepsis that indicate a specific regimen based on demonstration of superior efficacy.

OBJECTIVE

This review serves to examine preoperative antisepsis, including cutaneous bacteriology, preoperative hair removal, preoperative decolonization, surgical attire, and the antiseptic agents themselves.

MATERIALS AND METHODS

A review of the literature on surgical antiseptics was performed.

RESULTS

Although numerous studies have demonstrated differences in bacterial colonization rates, few well-controlled investigations have demonstrated superiority of a given regimen. The alcohol-based iodophor and chlorhexidine products seem to exhibit greater efficacy than their aqueous counterparts.

CONCLUSION

More randomized controlled trials will be needed to determine if any specific regimen is most effective. At this point in time, product usage should be based on specific attributes relating to the products, such as iodophors around the eyes and/or ears to avoid irritation and aqueous-based solutions in hair bearing areas because of concern for flammability. Ultimately, it is up to the individual surgeon to tailor the optimal antiseptic regimen for their specific scope of practice.

Surgical site infections in dermatologic surgery: etiology, pathogenesis, and current preventative measures

BACKGROUND

Surgical site infections (SSIs) after dermatologic surgery continue to represent undesirable complications that affect patients in several aspects. The etiology and pathogenesis of SSIs are not completely understood, and as a result, current preventative measures are debatable.

OBJECTIVE

To review and summarize the current available literature specific to SSIs in dermatologic surgery. The pathogenesis of SSIs, factors contributing to SSIs, current preventative guidelines, and evidence supporting their use are explored.

METHODS

A review of the medical literature.

RESULTS AND CONCLUSIONS

Most measures used to prevent SSIs in dermatologic surgery are based on studies of wounds in general surgery. Evidence specific to dermatologic surgery is scarce. More research related to the pathogenesis of SSIs is needed to establish effective preventative measures that are key to reducing incidences of SSIs.

Risk of complications due to anticoagulation during dermatosurgical procedures: a systematic review and meta-analysis

Background Management of anticoagulation and anti-platelet drugs during cutaneous surgery is still a challenge for many dermatologists and standards of care with respect to stopping, continuing or bridging vary widely. Methods We performed a systematic review (Medline, Cochrane Library, until August 27th, 2013) of studies assessing the risk of complications due to anticoagulation during cutaneous surgery. Primary outcomes were mild-moderate and severe postsurgical bleeding. The secondary outcomes were excessive and uncontrollable intraoperative bleeding and other postsurgical complications as wound dehiscence, erythema, wound infection. Results 1.287 publications were identified and 10 studies were included into the review. The frequencies of bleeding in the control groups in general were low (about 1%). In patients on aspirin, increased risks were seen neither with respect to mild-moderate postoperative bleeding (RR 1.1, CI 0.5-2.3), nor with respect to severe bleeding (RR 0.9, CI 0.2-4.6). The studies with patients on warfarin showed a risk for mild-moderate bleeding that was three times as high as in controls (RR 3.2, CI 1.4-7.1) and for severe bleeding that was 15 times higher (RR 14.8, CI 2.7-80.4). In general the study sizes were small and the methodological quality low. Conclusion The risk of bleeding due to a medication with aspirin seems to be negligible. With warfarin, the risk is increased; an exact estimate of the risk increase is difficult to give, because of the lack of sufficient high quality studies. A two-fold increase appears likely, the 15-fold increase is most likely due to statistical reasons arising from the rareness of the event in the small number of included patients. Stopping, bridging or continuing a medication should always be an individual decision. In accordance with guidelines from internal medicine for most patients it will be recommendable to continue with the medication.